Exam Latest Update 2024/2025 Questions
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• A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following
should occur during the orientation phase of the nurse-client relationship? - Correct Answers-Defining
responsibilities
• A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings
should the nurse report to the provider? - Correct Answers-Urine output 12 mL/hr
• A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a
contraction stress test. Which of the following statements by the client indicates an understanding of the
teaching? - Correct Answers-I am having this test because my baby was not reactive during a
nonstress test
a charge nurse in a long-term care facility is developing a performance improvement plan for an assistive
personnel (AP). Which of the following actions should the nurse take when developing the plans?
(Select all that apply) - Correct Answers-Set a specific time frame for meeting performance goals
Ask the nurse supervisor to review the plan
Include the performance standard that the AP should meet
A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall
precautions. Which of the following statements made by the nurse indicates an understanding of the
teaching? - Correct Answers-"I will instruct the client to sit when putting on a pair of pants"
A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a
client's medical information. Which of the following individuals should the charge nurse identify as
appropriate with whom to share client information? - Correct Answers-a social worker who is
assigned to an involuntary committed school age client
A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a
tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse
intervene? - Correct Answers-Suction for 30 seconds
A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit.
,Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching? - Correct Answers-"I will document in the medical record the support nurse who assists with
planning care for my clients"
A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following
actions by the newly licensed nurse should the supervising nurse intervene? - Correct Answers-Tells a
client he will lose his phone privileges if he does not take his medication
A charge nurse working in a long-term care facility overhears two AP's in the nurses stations discussing a
client who was just admitted. Which of the following actions should the charge nurse take? - Correct
Answers-Tell the APs to stop the conversation
A community health nurse is assisting in the development of a brochure about hypertension. Which of the
following actions should the nurse take? - Correct Answers-Explain the medical terminology using
basic one syllable words
A community health nurse is assisting with the development of a pamphlet regarding choking hazards for
toddlers. Which of the following foods should the nurse include? - Correct Answers-grapes
A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of the
following findings should the nurse identify as a safety risk? - Correct Answers-The client's electrical
wires are run under carpeting
A nurs is caring for a client wie suddenly develops chest pain and dyspea. Which of the following should
the nurse take first? - Correct Answers-Elevate the head of the client's bed
A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day.
The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an
example of which of the following? - Correct Answers-Countertransference
A nurse enters the room of a school age child and finds him on the food experiencing a tonic clonic
seizure. Which of the following actions should the nurse take? - Correct Answers-Place a pillow under
the child's head
A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of
vaginal fluids. Which of the following findings is evidence of an obstetric complication? - Correct
Answers-Appears greenish-brown in color
A nurse in a provider's office is collecting data from a client who has a history of hypertension during his
annual physical examination. Which of the following findings should the nurse report to the provider
immediately? - Correct Answers-blurred vision
A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following
statements made by the client should the nurse report to the provider ? - Correct Answers-" I try not to
look at the scales on my body."
A nurse in a providers office is reinforcing teaching about cigarette smoking. Which of the following
adverse effect should the nurse include in the teaching? - Correct Answers-Somnolence
, A nurse in an acute care setting is preparing to administer medications to a client. Which of the following
actions should the nurse verify the client's identity? - Correct Answers-Verify the client's identity
using a photograph
A nurse in an inpatient psychiatric unit is caring for a client who was raised in an Asian culture. Which of
the following communication techniques by the nurse demonstrates cultural sensitivity? - Correct
Answers-holding eye contact for brief instances
A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-
methamphetamine. Which of the following findings should the nurse expect? - Correct Answers-
hallucinations
A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following
outcomes should the nurse expect as a therapeutic effect of the treatment? - Correct Answers-Reduced
fat in the stools
A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction, which of the
following actions should the nurse take? - Correct Answers-Ensure that the weights are hanging freely
A nurse is assisting in the care of a client who has an arteriovenous (AV) shunt in his right arm. Which of
the following actions should the nurse take? - Correct Answers-check a bruit over the shunt on a
regular basis
A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased
bleeding. Which of the following actions should the nurse take? (Select all that apply) - Correct
Answers-Assist the client to empty her bladder
A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes
that the clients vagina and vulva are a purplish color. The nurse should document this finding as which of
the following? - Correct Answers-Chadwick's sign
A nurse is assisting with a support group for clients who have experienced intimate partner violence. The
nurse should identify which of the following client statements as indicating the greatest risk for violence?
- Correct Answers-I have decided to tell my husband I am leaving him
A nurse is assisting with discharge planning for a group of clients. Which of the following clients should
the nurse recommend a home health referral? - Correct Answers-An older adult client who has heart
failure and lives alone
A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the
following types of isolation precautions should the nurse include? - Correct Answers-airborne
A nurse is assisting with the admission of a client who has Vancomycin- resistant enterococcus of the
urine. Which of the following types of precautions should the nurse implement for this client? -
Correct Answers-contact precautions
A nurse is assisting with the admission of a client who has varicella zoster. Which of the following should
the nurse plan to implement? - Correct Answers-Initiate contact precautions for the client