LEVEL 4 2026 EXAMINATION TEST
COMPLETE QUESTIONS AND ANSWERS
WITH RATIONALES GUARANTEED TO PASS
⩥ A nurse is caring for a client who has dysphagia following a stroke.
Which of the following actions should the nurse take to facilitate safe
swallowing and decrease the risk of aspiration?
1. Delay the client's meal-time if he is fatigued.
2. Instruct the client to tilt his head to the side when swallowing.
3. Assist the client with fluid intake by inserting it into the client's mouth
with a syringe.
4. Encourage the client to focus on a television program during meal
time. Answer: Delay the client's meal-time if he is fatigued.
Rat: To facilitate safe swallowing and decrease the risk of aspiration, the
nurse should encourage the client to rest prior to meal-time. If the client
is fatigued, the nurse should delay the meal-time and give the client time
to rest.
⩥ A nurse in a long term care facility is performing a fall risk assessment
on a newly admitted client using the Timed Up and Go (TUG) test. The
,client reports using a tripod cane for ambulation. Which of the following
actions should the nurse take when using this test?
1. Observe the client ambulating a distance of 3 m (10 feet) during the
TUG test.
2. Instruct the client to perform the TUG test without the use of the cane.
3. Assist the client to stand up from the chair when starting the TUG test.
4. Advise the client to use the arms of the chair to stand when starting
the TUG test. Answer: Observe the client ambulating a distance of 3 m
(10 feet) during the TUG test.
Rat:The nurse should mark a spot 3 m (10 feet) away from the client's
sitting location. The nurse should instruct the client to stand, ambulate to
the marked spot, turn, ambulate back to the chair, and sit down. The
nurse should observe the client's ability to perform the test and use a
stopwatch to time the client. The nurse should identify that the client is
at increased risk of falls if it takes longer than 14 seconds to complete
the test.
⩥ A nurse in an emergency is caring for an infant who requires
emergency surgery. The infant is accompanied by his 16-year-old mother
and his maternal grandfather. Which of the following actions should the
nurse take when assisting with informed consent?
1. Witness consent obtained from the infant's mother.
,2. Inform the family that informed consent is not needed due to
emergency surgery.
3. Notify the maternal grandfather that he is required to give informed
consent.
4. Request that a court-appointed representative provide informed
consent.. Answer: Witness consent obtained from the infant's mother.
Rat: The nurse should assist in obtaining informed consent from the
infant's mother by witnessing her signature. Statutory guidelines indicate
that a minor, even if unemancipated, can provide consent for her infant.
Unemancipated minors can also legally provide informed consent for
STI treatment, substance use treatment, and care related to pregnancy in
some states.
⩥ A nurse is planning care to prevent a catheter-related blood stream
infection for a client who is receiving IV fluid therapy. Which of the
following interventions should the nurse include in the plan?
1. Change bags of IV solution every 72 hr.
2. Perform hand hygiene before touching the IV tubing.
3. Use hydrogen peroxide to cleanse the IV insertion site.
4. Assess the IV insertion site every 12 hr for redness.. Answer: Perform
hand hygiene before touching the IV tubing.
, Rat: The nurse should perform thorough hand hygiene before touching
any part of the infusion system or the client to reduce the risk of
catheter-related blood stream infections.
⩥ A nurse is caring for an adolescent client who is in critical condition
following a motor vehicle crash in which he was the passenger. The
clients parents shouts at the nurse, asking why her son is dying instead
of the driver. Which of the following actions should the nurse take to
provide emotional support to the patient?
1. Encourage the parent to speak with the family of the driver of the car.
2. Inform the parent that anger is a natural response when dealing with
loss.
3. Ask the parent to leave and come back later after she has calmed
down.
4. Contact a clergy member to come and speak with the parent.. Answer:
Inform the parent that anger is a natural response when dealing with
loss.
Rat: The nurse should identify that the parent is in the anger stage of
grief. The nurse should assist the parent to understand that anger is a
natural response to loss and encourage her to talk about her feelings.
⩥ A nurse is teaching about advice directives with an older adult client
who has a terminal illness. Which of the following statements should the
nurse make?