ACTUAL LATEST EXAM|
REVIEWED 2026/2027 | ALL795
QUESTIONS AND CORRECT
VERIFIED ANSWERS WITH
RATIONALES |GUARANTEED PASS
|ALREADY GRADED A+
1. The nurse assesses a client one hour after starting a transfusion of packed red
blood cells and determines that there are no indications of a transfusion
reaction. What instruction should the nurse provide the unlicensed assistive
personnel (UAP) who is working with the nurse?
A. Notify the nurse when the transfusion has finished, so further client
assessment can be done
B. Continue to measure the client's vital signs every thirty minutes
until the transfusion is complete
C. Monitor the client carefully for the next three hours and report the
onset of a reaction immediately
D. Since a reaction did not occur, the priority is to maintain client
comfort during the transfusion.....Answer......B. Continue to
measure the client's vital signs every thirty minutes until the
transfusion is complete
2. The healthcare provider prescribes a sepsis protocol for a client with multi-
organ failure caused by a ruptured appendix. Which intervention is most
important for the nurse to include in the plan of care?
A. Assess warmth of extremities
B. Keep head of bed raised 45 degrees
C. Monitor blood glucose level
D. Maintain strict intake and output.....Answer......D. Maintain strict
intake and output
,3. A client presses the call bell and requests pain medication for a severe
headache. To assess the quality of the client's pain, which approach should
the nurse use?
A. Ask the client to describe the pain
B. Observe body language and movement
C. Identify effective pain relief measures
D. Provide a numeric pain scale.....Answer......A. Ask the client to
describe the pain
4. A client presents to the labor and delivery unit with a report of leaking fluid
that is greenish-brown vaginal discharge. Which action should the nurse take
first?
A. Start an intravenous infusion
B. Administer oxygen via facemask
C. Perform a vaginal exam
D. Begin continuous fetal monitoring.....Answer......D. Begin
continuous fetal monitoring
5. A client asks the nurse for information about how to reduce risk factors for
benign prostatic hyperplasia (BPH). Which information should the nurse
provide?
A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test.....Answer......B.
Increase physical activity
6. The healthcare provider prescribes a fluid challenge of 0.9% sodium
chloride 1,000 mL to be infused intravenously over 4 hours. The IV
administration set delivers 10gtt/mL. How many gtt/minute should the nurse
regulate the infusion? (Round to the nearest whole number).....Answer......42
gtt/min
7. Following a cardiac catheterization and placement of a stent in the right
coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the
client. To monitor for adverse effects from the medication, which assessment
is most important for the nurse to include in this client's plan of care?
A. observe color of urine
B. Measure body temperature
C. Assess skin turgor
, D. Check for pedal edema.....Answer......A. Observe color of urine
8. A client fell in the bathroom when left unattended by the unlicensed assistive
personnel (UAP). Which information should the nurse include in the client's
health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip.....Answer......D.
The client fell sustaining a fracture to the left hip
9. The nurse is reviewing the diagnostic tests prescribed for a client with a
positive skin test. Which subjective findings reported by the client supports
the diagnosis of tuberculosis?
A. Barking cough and vomiting
B. Mucopurulent cough and night sweats
C. Dry cough and chest tightness
D. Chronic cough and fatty stools.....Answer......B. Mucopurulent
cough and night sweats
10.In assessing a client with type 1 diabetes mellitus, the nurse notes that the
client's respirations have changed from 16 breaths/min with a normal depth
to 32 breaths/min and deep, and the client become lethargic. Which
assessment data should the nurse obtain next?
A. Temperature
B. Breath sounds
C. Blood glucose
D. White blood cell count.....Answer......C. Blood glucose
11.A nurse receives report on a client who is four hours post-total abdominal
hysterectomy. The previous nurse reports that it was necessary to change the
client's perineal pad hourly and that it is again saturated. The previous nurse
also reports that the client's urinary output has decreased. Which action
should the nurse implement first?
A. Evaluate the skin turgor
B. Assess for weakness or dizziness
C. Change the perineal pad
D. Measure the urinary output.....Answer......B. Assess for weakness
or dizziness
, 12.The father of a 4-year-old has been battling metastatic lung cancer for the
past 2 years. After discussing the remaining options with his healthcare
provider, the client requests that all treatment stop and that no heroic
measures be taken to save his life. When the client is transferred to the
palliative care unit, which action is most important for the nurse working on
the palliative care unit to take in facilitating continuity of care?
A. Reassure the client that his child will be allowed to visit
B. Provide the client written information about end-of-life care
C. Obtain a detailed report from the nurse transferring the client
D. Mark the chart with client's request for no heroic
measures.....Answer......C. Obtain a detailed report from the nurse
transferring the client
13.While assessing a client who is admitted with heart failure and pulmonary
edema, the nurse identifies dependent peripheral edema, an irregular heart
rate, and a persistent cough that produces pink blood-tinged sputum. After
initiating continuous telemetry and positioning the client, which intervention
should the nurse implement?
A. Obtain sputum sample
B. Document degree of edema
C. Initiate hourly urine output measurement
D. Administer intravenous diuretics.....Answer......A. Obtain sputum
sample
14.A client who is admitted for primary hypothyroidism has early signs of
myxedema coma. In assessing the client, in which sequence should the nurse
complete these actions? (descending order).....Answer......1. Observe
breathing patterns
2. Assess blood pressure
3. Measure body temperature
4. Palpate for pedal edema
15.A client with type 2 diabetes mellitus arrives to the clinic reporting episodes
of weakness and palpitations. Which finding should the nurse identify may
indicate an emerging situation?
A. Potassium 3.5 mEq/L
B. Fingertips feel numb
C. Sodium 135 mEq/L
D. Cervical spine stiffness.....Answer......B. Fingertips feel numb