Answers 100% Correct (Latest Update 2025 /
2026)
1. The nurse is caring for a client who arrives to the emergency
department with reports of experiencing dizziness and difficulty
walking to the bathroom. The nurse observes right-sided
weakness and sluggish enunciation of speech. The nurse should
immediately take which action? ANS Start two large bore IV
catheters and review inclusion criteria for IV fibrinolytic therapy
2. The nurse is providing lifestyle change education for a client to
slow the progression of coronary artery disease. Which
statements made by the client should the nurse recognise as
needing additional education? ANS Consume foods with saturated
fats, Eat more canned vegetables
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,3. A client who is newly diagnosed with type two diabetes mellitus
receives a prescription for metformin 500 mg po twice daily.
Which information should the nurse include in these clients
teaching plan? ANS Recognize signs and symptoms of
hypoglycemia, Report persistent polyuria to the healthcare provider,
Take metformin with the morning and evening meal
4. A client is being urgently transported to radiology for a
Computerised Tomography (CT scan) after a sudden decrease in
level of consciousness. The client is orally intubated and has a
left lateral chest tube to 20 cm suction. Which action is most
important for the nurse to take? ANS Keep chest tube container
below the site of insertion
5. What action should the school nurse implement to provide
secondary prevention for school-aged children? ANS Initiate a
hearing and vision screening program for first graders
6. An older adult with a terminal illness is receiving hospice care
and is having difficulty coping with feelings related to death and
dying. Which intervention(s) should the nurse include in this
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,client’s plan of care? ANS Encourage family to visit frequently, Teach
client how to use guided imagery, Encourage family to bring the client
old photographs
7. A client who weighs 176 pounds receives a prescription for
enoxaparin sodium 1.5 mg/kg/day subcutaneous available in 120
mg/0.8 mL prefilled syringe. How many mL should the nurse
administer? ANS 0.8
8. The daughter of an older woman who has Parkinson’s disease,
calls the clinic and reports that her mother has been confused for
the past week. Which action(s) should the nurse take? ANS
Determine if the mother has recently experienced a fall, Ask if the
mother is experiencing any pain with urination, Instruct the daughter to
check her mother’s temperature
9. A client exposed to tuberculosis is scheduled to begin
prophylactic treatment with isoniazid. Which information is most
important for the nurse to note before administering the initial
dose? ANS Current diagnosis of hepatitis B
10. While caring for a toddler receiving oxygen via face mask, the
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, nurse observes that the child’s lips and nares are dry and
cracked. Which intervention should the nurse implement? ANS
Use a water soluble lubricant on affected oral and nasal mucosa
11. Which intervention is most important for the nurse to include
in the plan of care for a client who is 12 hours post
thyroidectomy? ANS Maintain a semi Fowler’s position
12. A mother brings her 4-month-old son to the clinic with a
quarter taped over his umbilicus, and tells the nurse the quarter is
supposed to fix her child’s hernia. Which explanation should the
nurse provide? ANS This hernia is a normal variation that resolves
without treatment
13. An older client admitted for observation following a fall while
getting out of the bath tub becomes increasingly confused. The
family arrives with the home medication list and the client’s
healthcare power of attorney. When providing a report to the
healthcare provider using SBAR (Situation, Background,
Assessment, Recommendation) communication, which
information should the nurse provide first? ANS Increasing
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