WITH COMPLETE QUESTIONS AND ANSWERS
GRADED A+ 2025/2026
A .nurse .is .caring .for .a .client .who .has .returned .to .the .unit .following .a .surgical .procedure.
.The .client's .oxygen .saturation .is .85%. .Which .of .the .following .actions .should .the .nurse
.take .first .? .
A. .Administer .O2 .at .2L/min .
B. .Administer .prescribed .analgesic .med .
C. .Encourage .coughing .and .deep .breathing .
D. .Raise .the .head .of .the .bed .- .CORRECT .ANSWER-D. .Raise .the .head .of .the .bed
Elevating .the .head .of .the .bed .uses .gravity .to .reduce .pressure .on .the .diaphragm .from .the
.abdominal .organs .and .allows .for .increased .expansion .of .the .lungs. .The .head .and .neck
.can .be .extended, .which .promotes .a .patent .airway. .This .is .the .first .action .the .nurse
.should .take .and .is .the .least .invasive.
A. .The .nurse .should .assess .the .client .further .and .implement .less .invasive .interventions
.before .applying .oxygen .at .2 .L/min.
B. .Pain .management .promotes .increased .participation .by .the .client .in .coughing .and .deep
.breathing, .frequent .position .changes .and .use .of .the .incentive .spirometer, .but .this .is .not
.the .first .action .the .nurse .should .take.
C. .Coughing .and .deep .breathing .promotes .lung .expansion .and .prevents .respiratory
.infection, .but .these .actions .are .not .effective .immediately .in .increasing .oxygen .saturation.
A .nurse .is .providing .teaching .to .a .client .who .has .neutropenia. .Which .of .the .following
.information .should .the .nurse .include .in .the .teaching?
,A. .Eat .plenty .of .fresh .fruits .and .vegetables
B. .Avoid .crowds
C. .Perform .mild .exercise, .such .as .gardening
D. .Take .temperatures .weekly .- .CORRECT .ANSWER-B. .Avoid .crowds
The .nurse .should .inform .the .client .to .avoid .crowds .due .to .his .suppressed .immune
.system.
A. .The .nurse .should .inform .a .client .who .is .neutropenic .to .avoid .fresh .fruits .and
.vegetables .due .to .the .bacteria .they .can .carry.
C. .The .nurse .should .instruct .the .client .to .avoid .gardening .due .bacteria .contained .in .the
.soil.
D. .A .client .who .is .neutropenic .can .experience .a .1° .increase .from .his .baseline
.temperature, .even .in .the .presence .of .infection. .Therefore, .the .nurse .should .recommend
.the .client .take .his .temperature .at .least .once .daily.
A .nurse .is .assessing .a .client .following .the .application .of .an .aquathermia .pad. .Which .of
.the .following .is .the .first .indication .to .the .nurse .that .the .client .is .experiencing .a
.superficial .burn .injury .to .the .application .site?
A. .Blistering
B. .Erythema .
C. .Eschar
D. .Absence .of .pain .- .CORRECT .ANSWER-B. .Erythema .
Erythema .is .an .indication .that .the .client .has .experienced .a .superficial .burn .with .damage
.limited .to .the .epidermis. .Other .manifestations .include .edema, .pain, .and .increased
.sensitivity .to .heat.
A. .Blistering .is .an .indication .of .a .superficial .partial .thickness .burn, .involving .injury .to .the
.upper .third .of .the .dermis. .These .injuries .also .are .pink .and .moist, .blanch .to .pressure .and
.are .very .painful.
C. .Eschar .is .seen .in .clients .who .have .a .full .thickness .wound .involving .the .epidermis .and
.dermis. .This .is .dead .tissue .that .must .be .removed .for .healing .to .occur
, D. .A .thermal .injury .that .is .not .painful .can .be .classified .as .a .deep .full-thickness .burn
.which .extends .into .muscle, .bone, .or .tendons.
A .nurse .in .a .long-tern .care .facility .enters .the .day .room .and .finds .the .window .curtains .on
.fire. .Clients .are .panicking .and .the .room .is .filling .with .smoke. .Indicate .the .emergency
.actions .the .nurse .must .take. .
Activate .the .fire .alarm. .
Extinguish .the .fire.
Close .the .door. .
Remove .the .clients .from .the .room. .- .CORRECT .ANSWER-Remove .the .clients .from .the
.room.
Activate .the .fire .alarm. .
Close .the .door. .
Extinguish .the .fire.
In .the .event .of .a .fire, .it .is .helpful .to .recall .the .mnemonic .RACE .to .prioritize .the .actions .to
.take: .R .- .Rescue .and .remove .the .clients, .A .- .Activate .the .alarm, .C .- .Confine .the .fire, .and
.E .- .Extinguish .the .fire. .The .nurse's .priority .action .is .to .remove .the .clients .from .the .room.
.The .nurse .should .then .sound .the .fire .alarm .and .close .the .door .to .confine .the .fire. .Finally
.and .if .possible, .the .nurse .should .extinguish .the .fire.
A .nurse .is .developing .a .plan .of .care .for .a .client .who .is .postoperative. .Which .of .the
.following .interventions .should .the .nurse .include .in .the .plan .of .prevent .pulmonary
.complications?
A. .Perform .ROM .exercises
B. .Place .suction .equipment .at .the .bedside
C. .Encourage .the .use .of .an .incentive .spirometer
D. .Administer .an .expectorant .- .CORRECT .ANSWER-C. .Encourage .the .use .of .an .incentive
.spirometer.
Incentive .spirometry .expands .the .lungs .and .promotes .gas .exchange .after .surgery .which
.can .help .prevent .pulmonary .complications.