COMPLETE QUESTIONS AND VERIFIED ANSWERS 2024-2025
A nurse is caring for a client who is in active labor and requests pain
management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position. - Answer B. Place the client in a warm
shower.
A nurse in an emergency department is performing triage for multiple
clients following a disaster in the community. To which of the following types
of injuries should the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm - Answer A. Below-the knee amputation
A nurse is assessing a newborn who has a blood glucose level of 30
mg/dl. Which of the following manifestations should the nurse expect?
A. Loose stools
B. Jitteriness
C. Hypertonia
D. Abdominal distention - Answer Jitteriness
A nurse in a pediatric clinic is reviewing the laboratory test results of a
school age child. Which of the following findings should the nurse report to
the provider?
A. Hgb 12.5 g/dl
B. Platelets 250,000/mm3
,C. Hct 40%
D. WBC 14,000/mm3 - Answer D. WBC 14,000/mm3
A charge nurse is teaching a newly licensed nurse about clients
designating a health care proxy in situations that require a durable power of
attorney for heal care (DPSHC). Which of the following information should the
charge nurse include?
A. "The proxy should make health care decisions for the client regardless
of the client's ability to do so."
B. "The proxy can make financial decisions if the need arises."
C. "The proxy can make treatment decisions if the client is under
anesthesia."
D. "The proxy should manage legal issues for the client." - Answer C. "The proxy can
make treatment decisions if the client is under anesthesia."
A nurse in the PACU is caring for a client who reports nausea. Which of
the following actions should the nurse take first?
A. Turn the client on their side.
B. Administer an analgesic
C. Administer antiemetic
D. Monitor the client's vital signs. - Answer A. Turn the client on their side.
A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-
old. Which of the following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure. - Answer B. Tell the
child they will feel discomfort during the catheter insertion.
,A nurse is caring for a client who has arteriovenous fistula Which of the
following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation. - Answer B. Absence of a bruit.
A nurse is providing discharge teaching for a client who has an
implantable cardioverter defibrillator which of the following statements
demonstrates understanding of the teaching?
A. "I will soak in the tub rather and showering"
B. "I will wear loose clothing around my ICD"
C. "I will stop using my microwave oven at home because of my ICD"
D. "I can hold my cellphone on the same side of my body as the ICD" - Answer B. "I
will wear loose clothing around my ICD"
A nurse is caring for a client who is at 14 weeks gestation and reports
feelings of ambivalence about being pregnant. Which of the following
responses should the nurse make?
A. "Describe your feelings to me about being pregnant"
B. "You should discuss your feelings about being pregnant with your
provider"
C. "Have you discussed these feelings with your partner?"
D. "When did you start having these feelings?" - Answer A. "Describe your feelings to
me about being pregnant"
A nurse is planning care for a client who has a prescription for a bowel-
training program following a spinal cord injury. Which of the following actions
should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per day.
, B. Increase the amount of refined grains in the client's diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled
defecation times. - Answer D. Administer a rectal suppository 30 minutes prior to
scheduled
defecation times.
A nurse is caring for a client who has a history of depression and is
experiencing a situational crisis. Which of the following actions should the
nurse take first?
A. Confirm the client's perception of the event
B. Notify the client's support system
C. Help the client identify personal strengths
D. Teach the client relaxation techniques - Answer A. Confirm the client's perception
of the event
A nurse is caring for a client who has bipolar disorder and is experiencing
acute mania. The nurse obtained a verbal prescription for restraints. Which
of the following actions should the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes. - Answer D. Document the
client's condition every 15 minutes.
A charge nurse on a medical-surgical unit is planning assignments for a
licensed practical nurse (LPN) who has been sent from the (Unable to read)
unit due to a staffing shortage. Which of the following client should the nurse
delegate to the LPN?
A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
B. A client who sustained a concussion and has unequal pupils.