WITH WELL VERIFIED QUESTIONS AND
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VERSION 2026
The home health nurse visits an elderly female client who had a brain attack
three months ago and is now able to ambulate with the assistance of a quad
cane. Which assessment finding has the greatest implications for this client's
care?
A. The husband, who is the caregiver, begins to weep when the nurse asks how
he is doing.
B. The client tells the nurse that she does not have much of an appetite today.
C. The nurse notes that there are numerous scatter rugs throughout the house.
D. The client's pulse rate is 10 beats higher than it was at the last visit one week
ago. - ANSWER-Scatter rugs (C) pose a safety hazard because the client can
trip on them when ambulating, so this finding has the greatest significance in
planning this client's care. Psychological support of the caregiver (A) is a less
acute need than that of client safety. The nurse needs to obtain more information
about (B), but this is not a safety issue. (D) is not a significant increase, and
additional assessment might provide information about the reason for the
increase (anxiety, exercise, etc.).
Correct Answer: C
The nurse removes the dressing on a client's heel that is covering a pressure sore
one-inch in diameter and finds that there is straw-colored drainage seeping from
the wound. What description of this finding should the nurse include in the
client's record?
A. Stage 1 pressure sore draining sero-sanguineous drainage.
B. Pressure sore at bony prominence with exudate noted.
,C. One-inch pressure sore draining serous fluid.
D. Pressure sore on heel with a small amount of purulent drainage. - ANSWER-
Serous drainage is clear watery plasma, so (C) provides accurate documentation
based on the information provided. Information to stage this pressure score (A)
is not provided, and sero-sanguineous drainage is pale and watery with a
combination of plasma and red cells, and may be blood-streaked. Exudate (B) is
fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or
brown indicating the presence of dead or living organisms and white blood
cells.
Correct Answer: C
A medication is prescribed to be given QID. What schedule should the nurse
use to administer this prescription?
A. 0800, 1200, 1600, 2000.
B. 800.
C. Every other day at 0800.
D. 0800, 1200, 1600, 2000, 0000, 0400. - ANSWER-(A) provides the best
schedule, because QID means four times per day. (B, C, and D) provide
incorrect dosages.
Correct Answer: A
A client who has been on bedrest for several days now has a prescription to
progress activity as tolerated. When the nurse assists the client out of bed for the
first time, the client becomes dizzy. What action should the nurse implement?
A. Encourage the client to take several slow, deep breaths while ambulating.
B. Help the client to remain standing by the bedside until the dizziness is
relieved.
C. Instruct the client to remain on bedrest until the healthcare provider is
contacted.
D. Advise the client to sit on the side of the bed for a few minutes before
standing again. - ANSWER-The nurse should implement (D), because
orthostatic hypotension is a common result of immobilization, causing the client
to feel dizzy when first getting out of bed following a period of bedrest. To
,prevent this problem, it is helpful to have the body acclimate to a standing
position by sitting upright for a short period (D) before rising to a standing
position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of
consciousness. (C) is not indicated and will increase the potential for
complications associated with prolonged immobility.
Correct Answer: D
The charge nurse observes an unlicensed assistive personnel (UAP) bending at
the waist to lift a 20-pound box of medical supplies off the treatment room
floor. What instruction should the charge nurse provide to the UAP?
A. Ask another staff member for assistance.
B. Request that supplies are delivered in smaller containers.
C. Push the box against the wall to provide support while lifting.
D. Bend at the knees when lifting heavy objects. - ANSWER-A 20-pound box
is safely lifted by bending the knees (D), holding the box close to the center of
gravity, and extending the legs using the quadriceps muscles. (A and B) might
be helpful, but the charge nurse should use this opportunity to reinforce proper
body mechanics techniques. Pushing the box against the wall (C) does not assist
with lifting.
Correct Answer: D
Which nursing intervention is most beneficial in reducing the risk of urosepsis
in a hospitalized client with an indwelling urinary catheter?
A. Ensure that the client's perineal area is cleansed twice a day.
B. Maintain accurate documentation of the fluid intake and output.
C. Encourage frequent ambulation if allowed or regular turning if on bedrest.
D. Obtain a prescription for removal of the catheter as soon as possible. -
ANSWER-The best intervention to reduce the risk for urosepsis (spread of an
infectious agent from the urinary tract to systemic circulation) is removal of the
urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce
the risk of infection, but are of less priority than (D) in reducing the risk of
urosepsis.
Correct Answer: D
, In evaluating client care, which action should the nurse take first?
A. Determine if the expected outcomes of care were achieved.
B. Review the rationales used as the basis of nursing actions.
C. Document the care plan goals that were successfully met.
D. Prioritize interventions to be added to the client's plan of care. - ANSWER-
In evaluating care, the nurse should first determine if the expected outcomes of
the plan of care were achieved (A). As indicated, the nurse may then review the
initial nursing actions and the rationales for those actions (B), document
successful completion of the care plan goals (C), and revise the plan of care (D).
Correct Answer: A
Prior to administering a newly prescribed medication to a client, the nurse
reviews the adverse effects of the medication listed in a drug reference guide
and determines the priority risks to the client. While performing this action, the
nurse is engaged in which step of the nursing process?
A. Assessment.
B. Analysis.
C. Implementation.
D. Evaluation. - ANSWER-The nurse is analyzing (B) data to establish an
individualized nursing diagnosis, such as, "Risk for injury related to side effects
of drugs." This analysis is based on assessment (A) and guides the planning and
implementation (C) of care, such as the decision to monitor the client
frequently. (D) provides the nurse with information about the effectiveness of
the plan of care.
Correct Answer: B
The nurses determines a client's IV solution is infusing at 250 ml/hr. The
prescribed rate is 125 ml/hr. What action should the nurse take first?
A. Determine when the IV solution was started.
B. Slow the IV infusion to keep vein open rate.