2024/2025 PRACTICE QUESTIONS WITH DETAILED
ANNSWERS
AznurseziszcaringzforzazclientzwhoziszreceivingzcontinuouszNGztubezfeedings.zTheznursezlistensztozthezclient'
szbowelzsounds.zWhichzofzthezfollowingzactionszshouldztheznurseztake?z(Clickzonzthezaudiozbuttonztozlisten
ztozthezclip.)z-zCORRECTzANSWER-Decreasezthezratezofzthezfeeding
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zRationality:zTheznursezshouldzexpectztozhearzbowelzsoundszeveryz5ztoz35zseconds.zThiszaudiozclipzindicate
szhypermotilityzbecauseztherezarezgreaterzthanz40zbowelzsounds/min.zHypermotilityzleadsztozdiarrheazan
dziszanzindicationzofzintoleranceztozthezenteralzfeeding.zTherefore,ztheznursezshouldzslowzthezratezofzthezfe
edingztozpromotezthezclient'sztolerancezofzthezfeeding.
TheznursezshouldzmaintainzazclientzwhoziszreceivingzcontinuouszNGztubezfeedingszinzazpositionzwithzthezhe
adzofzthezbedzelevatedz30°ztoz45°ztozpreventzaspirationzofzthezformula.
Aznurseziszpreparingztozadministerzoxygenztozazclientzwhozhaszheartzfailurezandziszhavingzseverezdifficultyz
breathing.zWhichzofzthezfollowingzoxygenzdeliveryzequipmentzshouldztheznursezselectztozprovidezthezhigh
estzconcentrationzofzoxygenztozthezclient?z-zCORRECTzANSWER-Nonrebreatherzmask
Rationality:
Aznonrebreatherzmaskzprovideszthezhighestzpercentagezofzoxygenzconcentrationzwithoutzintubationzandz
mechanicalzventilation.
AzVenturizmaskzcanzbezadjustedztozprovidezazconsistentzlowerzoxygenzconcentration.
Azsimplezfacezmaskzcanzbezadjustedzforzshort-termzdeliveryzofzlowztozmediumzoxygenzconcentration.
Aznasalzcannulazprovideszazlowzoxygenzconcentration.
Azchargeznursezsmellszsmoke,zenterszthezvisitorzrestroom,zandzseeszflameszinztheztrashzcan.zWhatziszthezse
quencezofzactionszthatztheznursezshouldztake?z(Movezthezstepszintozthezboxzonzthezright,zplacingzthemzinzt
,hezselectedzorderzofzperformance.zUsezallzthezsteps.)z-zCORRECTzANSWER-
Evacuatezclientszfromzthezareaziszthezfirstzstep.z
Rationality:zThezfirstzactionztheznursezshouldztakezwhenzusingzthezRACEzprotocolzisztoz"rescue"zorzevacuat
ezthezclientszfromzthezareaztozpreventzharm.
Pullzthezleverzonzthezfirezalarmzboxziszthezsecondzstep.z
Rationality:zForztheznextzstep,z"alarm,"ztheznursezshouldzactivatezthezfacilityzfirezalarmzandzcallztozreportzt
hezfireztozthezfacilityzemergencyzextension.
Closezthezfirezdoorszonzthezunitziszthezthirdzstep.z
Rationality:zClosezthezfirezdoorszonzthezunitziszthezthirdzstep.zForzthezthirdzstep,z"confine,"ztheznursezshoul
dzclosezthezunitzfirezdoorsztozpreventzthezfirezfromzspreading.
Usezazfirezextinguisherztozputzoutzthezfireziszthezfourthzstep.
Rationality:zForzthezfinalzstep,z"extinguish,"ztheznursezshouldzusezazfirezextinguisherztozputzoutzthezfirezbyz
aimingztheznozzlezatzthezbasezofzthezfirezandzusingzazsweepingzmotion.
AznurseziszcaringzforzazclientzwhozhaszmetastaticzcancerzandzpracticeszCatholicism.zThezclientzasksztheznurs
eztozdiscusszthezafterlifezwithzthem.zWhichzofzthezfollowingzstatementszbyztheznursezassistszinzmeetingzthe
zclient'szspiritualzneeds?z-zCORRECTzANSWER-"Tellzmezwhatzthezafterlifezmeansztozyou."
Rationale:zThiszstatementzrespectszthezclient'szspiritualzneedszbyzusingzopen-
endedztherapeuticzcommunicationztozassistzthezclientztoztalkzaboutztheirzconcerns.
Aznurseziszreinforcingzteachingzwithzazclientzaboutzthezpreventionzofzstresszinjuries.zWhichzofzthezfollowin
gzinstructionszshouldztheznursezinclude?z-zCORRECTzANSWER-
"Whenzliftingzazheavyzobject,zkeepzitzcloseztozyourzbody."
, Rationality:zTheznursezshouldzinstructzthezclientztozkeepzthezobjectzaszcloseztoztheirzbodyzaszpossibleztozin
creasezstabilityzandzdecreasezbackzstrainzwhenzliftingzazheavyzobject.
Aznurseziszreinforcingzteachingzwithzazclientzaboutzthezusezofzcrutches.zWhichzofzthezfollowingzactionszbyzt
hezclientzindicateszanzunderstandingzofzthezteaching?z-zCORRECTzANSWER-
Thezclientzadvanceszthezunaffectedzlegzfirstzwhilezclimbingzstairs.
Rationality:zWhenzascendingzstairs,zthezclientzshouldzfirstzadvancezthezunaffectedzleg.
Theznursezshouldzreinforcezwithzthezclientzthatztheirzaxillazshouldznotzbearzanyzweightzwhilezinztheztripodz
positionzbecausezthiszcanzcausezpressurezinjuryzformation.zThezclientzshouldzbearztheirzweightzwithztheirz
armszandzhands.
Azclientzwhozhaszadvancedzcancerztellsztheznursezthatztheyzhavezazdifficultztimeztalkingztozanyonezaboutzth
ezillness.zWhichzofzthezfollowingzactionszshouldztheznurseztakeztozencourageztherapeuticzcommunication?
z-zCORRECTzANSWER-Letzthezclientzknowzthat,zasztheirznurse,ztheyzarezavailablezandzwillingztozlisten.
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zRationality:zActivezlisteningzconveysztheznurse'szrespectzandzacceptancezforzthezclient'szfeelingszandzgives
zthezclientzanzopportunityztozexpressztheirzthoughtszandzneeds.
Aznurseziszpreparingztozremovezazclient'szperipheralzIVzcatheter.zAfterzperformingzhandzhygienezandzapplyi
ngzcleanzgloves,zwhichzofzthezfollowingzactionszshouldztheznurseztakezfirst?z-zCORRECTzANSWER-
Clampzthezinfusionztubing.
Rationality:zEvidence-
basedzpracticezindicateszthatztheznursezshouldzfirstzclampzthezinfusionztubingzafterzapplyingzcleanzgloves.z
ThiszactionzstopszthezflowzofzthezIVzfluidzandzpreventszitzfromzleakingzoutzduringzthezIVzremoval.
Aznurseziszcontributingztozthezplanzofzcarezforzazclientzwhozhaszazpositivezthroatzculturezforzstreptococci.z
Whichzofzthezfollowingzinterventionszshouldztheznursezrecommendztozbezincludedzinzthezplanzofzcare?z-
zCORRECTzANSWER-
Ensurezthatzthezclientzwearszazsurgicalzmaskzduringztransportationzthroughoutzthezfacility.