LATEST VERSION QUESTIONS AND VERIFIED
CORRECT ANSWERS JUST RELEASED
A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. Feet elevated
c. High fowlers'
d. Side lying - answer>>>c. high fowlers
A nurse is teaching a client how to use a quad cane for ambulation following a right-
hemispheric stroke. Which of the following client actions indicates an understanding of
the teaching?
a. Client takes a step before advancing the cane
b. Client holds the cane with the left hand
c. Client moves the cane 2 feet ahead
d. Client advances the weaker leg forward first - answer>>>d. Client advances the
weaker leg forward first
A nurse is providing discharge teaching for a client who has new tracheostomy. Which
of the following statements by the client indicates an understanding of the teaching?
a. "ill remove the soiled tracheostomy ties prior to cleansing my stoma"
b. "ill cut a slit in a clean gauze pad to use as a stoma dressing"
c. "ill insert the obturator after cleaning my stoma"
d. "ill cleanse the cannula with half-strength hydrogen peroxide" - answer>>>c. I'll insert
the obturator after cleaning my stoma
A nurse is preparing to administer furosemide to a client who has acute heart failure.
Which of the following laboratory results should the nurse identify as contraindications
for receiving the medications?
a. BUN 18 mg/dl
b. Creatinine 0.8 mg/dl
c. Potassium 3.2 mEq/l
d. Sodium 136 meEq/l - answer>>>c. Potassium 3.2 mEq/l
A nurse is caring for a client admitted with a skull fracture. Which of the following
,assessment findings should be of greatest concern to the nurse?
a. Bilateral pupil diameter changes from 4 to 2 mm
b. WBC count changes from 9,000 to 16,000/mm3
c. Pulse pressure changes from 30 to 20 mm Hg
d. Glasgow Coma Scale score changes from 14 to 9 - answer>>>d. GCS score changes
from 14 to 9
A nurse is assessing a client who has myasthenia gravis. Which of the following client
statements should indicate to the nurse that the client needs a referral for occupational
therapy?
a. "I have a hard time with brushing my hair"
b. "I would rather be in a wheelchair than use a walker to get around"
c. "I've been having problems with bladder control"
d. "I have difficulty swallowing food" - answer>>>a. I have a hard time with brushing my
hair
A nurse is providing discharge teaching to a client who will be self-administering insulin
at home. Which of the following information should the nurse include regarding needle
disposal?
a. "secure the cap tightly over the needle before you discard it"
b. "remove the needle from the syringe before you place it in the trash"
c. "you can discard needles in an empty bleach bottle with a lid"
d. "place your storage container in a recycle bin when it is full" - answer>>>c. you can
discard needles in an empty bleach bottle with a lid
A nurse is assessing a client who has arteriovenous (AV) graft in the left forearm. Which
of the following findings should indicate to the nurse a complication of vascular access?
a. 2+ left radical pulse
b. Absence of a bruit
c. Presence of a palpable thrill
d. Dilated appearance of the AV site - answer>>>b. Absence of a bruit
A client who is deaf and communicates using sign language is being admitted by a
nurse who does not know sign language. Which of the following actions should the
nurse take?
a. Familiarize themselves with commonly used sign language
b. Ask a family member to be present during the admission
c. Obtain a board that uses colored pictures as communication
, d. Request an interpreter during the initial assessment - answer>>>d. Request an
interpreter during the initial assessment
A nurse is planning care for a client who has unrepaired intertrochanteric fracture and
has Buck's traction placed to the affected leg. Which of the following interventions
should the
nurse include?
a. Situate the client's heel in the heel of the traction boot
b. Apply weights of the traction to total 9.1 kg (20lb)
c. Place the footplate against the foot of the bed
d. Remove the boot for skin inspection every 12 hours. - answer>>>a. Situate the client's
heel in the heel of the traction boot
A nurse is caring for a client who sustained a spinal cord injury in a diving accident.
Which of the following actions should the nurse take?
a. Assess the client's neurological status every 8 hour
b. Monitor urine output hourly
c. Provide the client with a low-fiber diet
d. Log roll the client every 4 hour - answer>>>b. Monitor urine output hourly
A nurse is planning care for a client who has a central venous access device for
intermittent infusions. Which of the following actions should the nurse include in the
plan
of care?
a. Flush the catheter using a 10ml syringe
b. Change the dressing every 24 hour
c. Use clean technique when changing the dressing
d. Cleanse the site with povidone-iodine - answer>>>a. Flush the catheter using a 10ml
syringe
A nurse in the emergency department is caring for a client who has a gunshot wound to
the abdomen. Which of the following actions should the nurse take first?
a. Check the color of the client's skin
b. Remove all of the client's clothing
c. Administer an opioid analgesic
d. Prepare the client for periorbital lavage - answer>>>a. Check the color of the client's
skin