TESTED VERSIONS OF THE EXAM FROM
2025 TO 2026 | ACCURATE AND VERIFIED
ANSWERS | NEXT GEN FORMAT |
GUARANTEED PASS
1. A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of
the following information should the nurse include in the teaching?
A. Interlace the fingers while rubbing hands together. ✅
B. Apply friction to hands for 10 seconds.
C. Use hot water to wash hands.
D. Dry hands starting from forearm to fingers.
Correct Answer: A
Rationale: Interlacing fingers ensures all surfaces of the hands are properly cleaned. The CDC
recommends 20 seconds of friction and warm (not hot) water.
2. A nurse is caring for a client who is receiving morphine for pain. Which of the following
findings indicates that the client is experiencing an adverse effect of the medication?
A. Tachycardia
B. Lacrimation
C. Hypertension
D. Urinary retention ✅
Correct Answer: D
Rationale: Morphine can cause urinary retention due to its effect on smooth muscle tone and
the central nervous system.
3. A nurse is caring for a child who has terminal cancer. Which of the following responses by
the child's school-age brother should the nurse expect?
A. Regresses to an earlier developmental level
B. Alienates himself from his peers
C. Believes his bad behavior is causing his brother's death ✅
D. Believes that his brother's death will be reversible
Correct Answer: C
Rationale: School-age children often have magical thinking and may believe they caused a
sibling's illness or death through bad behavior.
,4. A nurse is reinforcing teaching about advance directives with a client who has end-stage
heart failure. Which of the following statements by the client indicates an understanding of
the teaching?
A. "I am not allowed to change my mind once I sign this document."
B. "I should discuss this document with my family after I sign it." ✅
C. "My partner needs to be present when I sign this document."
D. "An attorney will need to notarize this document for it to be valid."
Correct Answer: B
Rationale: It is essential that the client communicates their wishes to family members to ensure
that the directive is respected.
5. A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin
via IV infusion. Which of the following manifestations should the nurse identify as an adverse
effect of the treatment?
A. Hypotension
B. New onset of hearing loss ✅
C. Hyperthermia
D. Slurred speech
Correct Answer: B
Rationale: Gentamicin is ototoxic; hearing loss is a serious adverse effect and requires prompt
attention.
6. A nurse enters a client's room and finds her sitting on the floor next to the shower. The
client states that she slipped on some water. Which action should the nurse take first?
A. Complete an incident report.
B. Notify the client's provider.
C. Document the fall in the client's record.
D. Measure the client's vital signs ✅
Correct Answer: D
Rationale: The nurse must first assess for injury or complications before taking further steps.
7. A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes the client
is in the "taking-in phase" of maternal adjustment. Which of the following should the nurse
expect?
A. Tolerates physical discomforts
B. Is eager to review the birth experience ✅
C. Begins reconnecting with their partner
D. Performs self-care independently
, Correct Answer: B
Rationale: During the "taking-in" phase, mothers focus on themselves and want to recount their
birthing experience.
8. A nurse caring for the family of a client who recently died. What action should the nurse
take?
A. Instruct the family to leave prior to cleaning the body.
B. Encourage the family to express their feelings of loss ✅
C. Limit time spent in the room.
D. Ask the family not to touch the body.
Correct Answer: B
Rationale: Supporting emotional expression aids in the grieving process.
9. A nurse is caring for a client with a terminal illness. Which finding indicates hopelessness?
A. Decreased energy level
B. Requests a second opinion
C. Talks about the diagnosis with staff
D. Makes funeral arrangements ✅
Correct Answer: D
Rationale: Planning for death may reflect a loss of hope or acceptance, indicating a possible
need for emotional support.
10. A nurse notes an evisceration from a surgical site. What action should the nurse take?
A. Instruct the client to lie supine with knees flexed ✅
B. Position in semi-Fowler's
C. Cover wound with a dry dressing
D. Use transparent dressing
Correct Answer: A
Rationale: Supine with knees flexed reduces abdominal pressure and prevents further
protrusion.
11. A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which food
is highest in potassium?
A. Sweet potato ✅
B. Baked chicken breast
C. Wheat bread
D. Canned green beans
Correct Answer: A
Rationale: Sweet potatoes are rich in potassium, important for clients at risk of hypokalemia.