EXAM 2022 EXAM ALL 180 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY
GRADED A+
Allergic Reaction - ANSWER: Indicated by joint pain as a response to medication
Auditory Hallucinations - ANSWER: Schizophrenic client hearing voices telling them
to harm others
Electroconvulsive Therapy - ANSWER: Treatment for depression with increased risk
due to hyperthyroidism
Rheumatoid Arthritis - ANSWER: Nurse should report ESR of 75 mm/hr in a client's
lab results
Mechanical Ventilation - ANSWER: Effective suctioning indicated by decreased peak
inspiratory pressure
Seclusion Room - ANSWER: Client with violent behavior should be managed
assertively by the nurse
Adrenalectomy - ANSWER: Priority postoperative action is monitoring fluid and
electrolyte status
Surgical Procedure - ANSWER: Nurse should respect client's decision to refuse
surgery
Borderline Personality Disorder - ANSWER: Improved condition indicated by
decreased clinging behavior
Healthy Snack Options - ANSWER: Nurse should recommend air-popped popcorn for
school-age children
Enoxaparin - ANSWER: Nurse should teach client to take acetaminophen for pain
relief concurrently
Fibromyalgia - ANSWER: Nurse should administer pregabalin for pain in a client with
fibromyalgia
Digoxin Toxicity - ANSWER: Risk indicated by potassium level of 3.1 mEq/L in a client
with CHF
Alteplase - ANSWER: Contraindicated in a client with a history of hip arthroplasty 1
week ago
, Implantable Cardioverter Defibrillator - ANSWER: Client understands teaching if they
avoid microwave oven use
Indwelling Urinary Catheter - ANSWER: Dark yellow urine drainage at 25ml/hr
requires obtaining a urine specimen
Stillbirth - ANSWER: Nurse should offer to take pictures of the newborn for the
grieving client
Burn Injury - ANSWER: Priority action to prevent wound infection is using sterile
dressings
Alzheimer's Disease - ANSWER: Nurse should assist caregiver in arranging a daycare
program for the client
Postpartum Urinary Retention - ANSWER: Nurse should perform a fundal massage
for a client unable to urinate
Medication Reconciliation - ANSWER: Nurse should compare home medications to
admission prescriptions
Betamethasone - ANSWER: Adverse effect is hypotension in a client with preterm
labor at 25 weeks gestation
Central Venous Catheter Blood Sample - ANSWER: Actions include aspirating for
blood return and flushing with sodium chloride
Preschooler Dressing Change - ANSWER: Prepare child by explaining the procedure in
simple terms
Deep-breathing methods - ANSWER: Techniques taught to a child before a medical
procedure.
Abdominal incision wound care - ANSWER: Process including irrigating with a 10-mL
syringe and using low-pressure flow.
Client prioritization - ANSWER: Determining which client to see first based on
conditions like gestation week and symptoms.
Amputation recovery report - ANSWER: Information to share with an occupational
therapist, e.g., living situation and allergies.
Supporting a depressed client - ANSWER: Appropriate responses to a client
expressing loneliness and lack of care.