2024|VERIFIED EXAM QUESTIONS AND CORRECT
ANSWERS ALL GRADED A+|GUARANTEED
SUCCESS|LATEST UPDATE 2024-2025
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing
diarrhea and who might have a right ear infection. Which of the following routes
should the nurse use to obtain the temperature? - ANSWER-✅Temporal
A nurse is caring for a client who is in the terminal stage of cancer. Which of the
following actions should the nurse takes when she observes the client crying? -
ANSWER-✅Sit and hold the client's hand
A community health nurse is preparing a campaign about seasonal influenza. Which
of the following plans should the nurse include as a secondary prevention? -
ANSWER-✅Screening groups of older adults in nursing care facilities for early
influenza manifestations
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of
the following statements by the AP indicates an understanding of the teaching? -
ANSWER-✅"There are times I should use soap and water rather than an alcohol-
based rub to clean my hands."
A nurse is performing an abdominal assessment for an adult client. Identify the
correct sequence of steps for this assessment. - ANSWER-✅- Inspection
- Auscultation
- Percussion
- Palpation
A nurse at a screening clinic is assessing a client who reports a history of a heart
murmur related to aortic valve stenosis. At which of the following anatomical areas
should the nurse place the stethoscope to auscultate the aortic valve? - ANSWER-
✅Second intercostal space to the right of the sternum
A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take? - ANSWER-✅Count the apical
pulse rate for 1 minute, and describe the rhythm in the chart
, A nurse observes an assistive personnel (AP) preparing to obtain blood pressure
with a regular size cuff for a client who is obese. Which of the following explanations
should the nurse give the AP? - ANSWER-✅"Using a cuff that is too small will result
in an inaccurately high reading."
A nurse is admitting a client who has decreased circulation in his left leg. Which of
the following actions should the nurse take first? - ANSWER-✅Evaluate pedal pulses
A nurse is preparing to provide tracheostomy care for a client. Which of the
following actions should the nurse take first? - ANSWER-✅Perform hand hygiene
A nurse is caring for a client who requires a chest x-ray. Prior to the client being
transported for the procedure, which of the following actions should the nurse take
first? - ANSWER-✅Identify the client using two identifiers
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the
following actions should the nurse take? - ANSWER-✅Place the bladder of the cuff
over the posterior aspect of the thigh
A nurse on a medical-surgical unit is washing her hands prior to assisting with a
surgical procedure. Which of the following actions by the nurse demonstrates proper
surgical hand-washing technique? - ANSWER-✅The nurse washes with her hands
held higher than her elbows
A nurse is caring for a client who is unstable and has vital signs measured every 15
minutes by an electronic blood pressure machine. The nurse notes the machine
begins to measure the blood pressure at varied intervals and the readings are
inconsistent. Which of the following actions should the nurse take? - ANSWER-
✅Disconnect the machine, and measure the blood pressure manually every 15
minutes
A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take? - ANSWER-✅Raise the level of the
bed
A nurse is inserting an IV catheter for a client that results in a blood spill on her
gloved hand. The client has no documented bloodstream infection. Which of the
following actions should the nurse take? - ANSWER-✅Carefully remove the gloves
and follow with hand hygiene
A nurse is assessing the heart sounds of a client who has developed chest pain that
becomes worse with inspiration. The nurse auscultates a high-pitched scratching
sound during both systole and diastole with the diaphragm of the stethoscope
positioned at the left sternal border. Which of the following heart sounds should the
nurse document? - ANSWER-✅Pericardial friction rub