TEST BANK FOR HESI RN Exit Exam 2024/2025 Versions 1–7 (v1,v2,v3,v4,v5,v6,v7,) + BONUS Past Papers for HESI RN EXIT EXAMS From 2018 – 2024 with Diagrams, Rationales & Pictures | Rated Grade A+| verified questions & answers | Brand new!! ( 2024/2025)

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HESI RN Exit Exam 2025 test bank HESI exit exam questions and answers V1–V7 HESI RN Exit V7 2025 actual exam 2025 HESI RN final exam with rationales HESI V1 to V7 verified questions 2025 Latest HESI RN exit exam test bank PDF HESI RN NCLEX prep 2025 updated version RN Exit HESI 2025 real questions A+ graded HESI 2025 V1-V7 nursing exit exam review Download HESI RN V1 V2 V3 V4 V5 V6 V7 answers hesi rn exit exam 2025 hesi exit exam test bank hesi version 1 to 7 2025 nclex rn hesi prep hesi 2025 exam answers hesi rn latest questions hesi v1-v7 real exam hesi rn rationales pdf hesi exit practice test hesi nursing questions verified 2025 hesi final exam bank hesi rn test with answers HESI RN Exit Exam Test Bank 2025/2026 (Versions 1–7) + BONUS Past Papers 2022–2024 with Diagrams, Rationales & Pictures TABLE OF CONTENTS HESI RN Exit Exam v1 3 HESI RN Exit Exam v2 149 HESI RN Exit V3 204 HESI Exit RN V4 261 HESI Exit RN V5 304 HESI Exit RN V6 349 HESI EXIT RN V7 391 ADDITIONAL HESI EXIT RN EXAM V1-V7 PAST PAPER FROM WITH PICTURES,RATIONALES AND DIAGRAMS 528 WISHING YOU ALL THE BEST AS YOU EXPLORE THE BEST MASTERPIECE EVER RATE MY WORK FOR MORE HESI EXIT EXAMS V1 – V7 HESI RN Exit Exam v1 The nurse is completing the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope - - ANSWER-- B. Sluggish and unequal pupillary responses Rationale: Sluggish and unequal pupillary responses are a direct sign of increased intracranial pressure affecting cranial nerves, particularly the oculomotor nerve (cranial nerve III). These findings indicate neurologic deterioration and warrant immediate intervention. Explanation of Incorrect Options: • A. Tachycardia and tachypnea: These are nonspecific findings and may occur with fever or infection but are not reliable indicators of increased ICP. In fact, bradycardia (not tachycardia) is often seen with rising ICP. • C. Increased head circumference and bulging fontanels: These are signs more typically seen in infants due to open sutures. By 3 years of age, the fontanels are generally closed, making this less likely. • D. Blood pressure fluctuations and syncope: While late signs of increased ICP can include changes in vital signs, syncope is not typically associated with elevated ICP in children and is more common with cardiac or vasovagal events. Test-Taking Tip: In pediatric patients, neurologic signs like pupillary changes and altered level of consciousness are more reliable indicators of increased ICP than general signs such as changes in heart rate or respiratory rate. Know which signs are age-appropriate. DIF: Analysis REF: Pediatric Nursing: Content Review and NCLEX®-Style Q&A OBJ: Neurological assessment and prioritization in pediatrics TOP: Pediatric Neurological Disorders ________________________________________ A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? A. Abdominal pain decreases when lying supine B. Pain lasts an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula D. Drinks alcohol until intoxicated at least twice weekly. - - ANSWER--A. Abdominal pain decreases when lying supine Rationale: Chronic or binge alcohol consumption is one of the most common causes of acute pancreatitis. Alcohol leads to inflammation of the pancreatic ducts and premature activation of pancreatic enzymes, which results in autodigestion of the pancreas and intense abdominal pain. Explanation of Incorrect Options: • A. Abdominal pain decreases when lying supine: This is incorrect. Pancreatic pain typically worsens when lying flat and improves when sitting up and leaning forward. • B. Pain lasts an hour and leaves the abdomen tender: Pancreatic pain is persistent and severe, often lasting for hours to days. It is not typically transient. • C. Right upper quadrant pain refers to right scapula: This description is more characteristic of biliary colic or gallbladder disease, not pancreatitis, which typically causes epigastric pain radiating to the back. Test-Taking Tip: When evaluating abdominal pain, always consider risk factors like alcohol use or gallstones for pancreatitis. Pain that radiates to the back and worsens when lying flat is classic for pancreatitis, often with a history of alcohol use. DIF: Analysis REF: Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care OBJ: Identify contributing factors and symptom patterns in GI disorders TOP: Gastrointestinal Disorders – Pancreatitis ________________________________________ . A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Instructions about how much fluid the child should drink daily. B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures D. Referral for social services for the child and family - - ANSWER--A. Instructions about how much fluid the child should drink daily Rationale: Adequate hydration is critical in preventing red blood cell sickling and subsequent vaso occlusive crises in children with SCA. Teaching parents the daily fluid requirements helps reduce the risk of dehydration—a common trigger for painful sickle cell episodes. Explanation of Incorrect Options: • B. Signs of addiction to opioid pain medications: While monitoring for side effects is important, preventing crises through hydration takes priority over concerns about long term addiction in pediatric SCA management. • C. Information about non-pharmaceutical pain relief measures: Non pharmacologic strategies (e.g., warm compresses, distraction) can support comfort but do not address the primary preventive measure of maintaining hydration. • D. Referral for social services for the child and family: Social support may be beneficial, but the immediate teaching priority is a clinical intervention that directly prevents complications. Test-Taking Tip: When multiple teaching topics apply, prioritize interventions that directly prevent acute complications—in SCA, maintaining hydration is a first line preventive strategy. DIF: Analysis REF: Pediatric Nursing: Caring for Children and Their Families OBJ: Teach preventive self care measures for sickle cell anemia TOP: Hematologic Disorders – Sickle Cell Anemia ________________________________________ Question: A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on the hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? Options: A. Assess the child for altered sensorium B. Determine type of chemical exposure C. Obtain equipment for gastric lavage D. Call poison control emergency number Correct Answer: B. Determine type of chemical exposure Rationale: Identifying the specific chemical involved is essential in managing poisoning or toxic exposure. The treatment plan—including whether to perform gastric decontamination, administer antidotes, or provide supportive care—depends on the type, route, and severity of the exposure. Early identification allows the care team to take targeted and appropriate action. Explanation of Incorrect Options: • A. Assess the child for altered sensorium: While neurological assessment is important, it comes after identifying the chemical to guide specific interventions. • C. Obtain equipment for gastric lavage: Gastric lavage is rarely recommended in pediatric poisonings and should never be initiated before knowing the substance ingested due to the risk of further harm (e.g., with caustics or hydrocarbons). • D. Call poison control emergency number: This is a critical step but should follow immediate clinical assessment and identification of the substance. The team may need details about the product before calling poison control. Test-Taking Tip: In poisoning cases, the priority after airway safety is to identify the substance involved. Treatment varies widely by chemical, and incorrect interventions can cause serious harm if the agent is unknown. DIF: Application REF: Pediatric Emergency Nursing, Emergency Nursing Core Curriculum OBJ: Prioritize actions for suspected toxic exposure in children TOP: Pediatric Toxicology – Emergency Care ________________________________________ Question: An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all that apply. Options: A. Ask if the mother is experiencing any pain with urination B. Encourage increased intake of high protein foods C. Instruct the daughter to check her mother's temperature D. Review the client's current food and medication allergies E. Determine if the mother has recently experienced a fall Correct Answers: A. Ask if the mother is experiencing any pain with urination C. Instruct the daughter to check her mother's temperature E. Determine if the mother has recently experienced a fall Rationale: Sudden confusion in older adults, particularly with worsening at night (a phenomenon known as sundowning), often indicates delirium rather than dementia. Common causes include infections such as urinary tract infections (UTIs), fever, and head trauma from recent falls. These must be promptly assessed and ruled out. Explanation of Incorrect Options: • B. Encourage increased intake of high protein foods: While nutrition is important for general health, it is not an immediate priority in evaluating sudden cognitive decline. • D. Review the client's current food and medication allergies: This is part of routine assessment but is not a priority action in response to acute changes in mental status. Test-Taking Tip: In older adults, new-onset confusion is often due to acute, reversible medical issues—not dementia. Always think infection, trauma, or metabolic changes first. Prioritize questions that uncover potential reversible causes. DIF: Analysis REF: Gerontologic Nursing, Evidence-Based Practice for Older Adults OBJ: Assess acute cognitive changes in older clients TOP: Delirium and Acute Confusion in Older Adults ________________________________________ Question: The nurse is assessing a male with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? Options: A. Hypertonic saline solution at 100 mL/hr until all edema disappears B. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg C. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves D. Regular insulin drip to keep blood glucose around 100 mg/dL (5.55 mmol/L) Correct Answer: B. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg Rationale: In an Addisonian crisis (acute adrenal insufficiency), the priority is immediate IV glucocorticoid replacement. Hydrocortisone is the drug of choice because it provides both glucocorticoid and mineralocorticoid effects. It helps restore blood pressure, glucose levels, and fluid/electrolyte balance. Without this intervention, the condition can be life-threatening. Explanation of Incorrect Options: • A. Hypertonic saline solution at 100 mL/hr until all edema disappears: Addison's crisis is associated with dehydration and hypotension—not fluid overload. Isotonic fluids (like 0.9% normal saline) are typically used to restore circulating volume, not hypertonic saline. • C. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves: Potassium is usually elevated in Addisonian crisis due to aldosterone deficiency, so administering potassium could be dangerous. • D. Regular insulin drip to keep blood glucose around 100 mg/dL: Hypoglycemia may occur in adrenal insufficiency, but insulin would worsen it. The goal is to raise glucose levels, not lower them. Test-Taking Tip: In endocrine emergencies, always match the specific hormone deficiency to its reversal treatment. For Addisonian crisis, IV hydrocortisone is the first-line intervention. DIF: Application REF: Brunner & Suddarth's Textbook of Medical-Surgical Nursing OBJ: Identify priority treatments for adrenal crisis TOP: Endocrine Emergencies – Adrenal Insufficiency ________________________________________ ________________________________________ Question: A client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include in the client's plan of care? Select all that apply. Options: A. Monitor cardiac rhythm via telemetry B. Report changes in pre-existing murmurs C. Schedule rest periods between activities D. Maintain record of fluid intake and output E. Initiate contact transmission precautions Correct Answers: A. Monitor cardiac rhythm via telemetry B. Report changes in pre-existing murmurs C. Schedule rest periods between activities D. Maintain record of fluid intake and output Rationale: Infective endocarditis can cause complications such as arrhythmias, valvular dysfunction, embolic events, and heart failure. Monitoring cardiac rhythm helps detect conduction abnormalities. Changes in murmurs may indicate worsening valvular damage. Fatigue is common, so rest periods are essential. Tracking fluid balance helps monitor for heart failure, especially if the infection compromises cardiac output. Explanation of Incorrect Options: • E. Initiate contact transmission precautions: Infective endocarditis is not typically transmitted person-to-person. Standard precautions are sufficient unless another transmissible infection (e.g., MRSA, C. difficile) is present. Test-Taking Tip: When managing infective endocarditis, think about cardiac monitoring, embolic risks, and energy conservation. Murmurs and conduction issues often worsen as valve damage progresses—look for those signs. DIF: Analysis REF: Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care OBJ: Plan nursing interventions for clients with cardiac infections TOP: Cardiovascular Infections – Infective Endocarditis ________________________________________ ________________________________________ Question: The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants? Options: A. Remove pillows and soft toys from the crib at bedtime B. Keep a bulb syringe accessible for use for an infant C. Position the infant in a supine position while sleeping D. Do not prop bottles for an infant during naps and bedtime Correct Answer: C. Position the infant in a supine position while sleeping Rationale: Placing infants on their backs (supine position) to sleep is the most effective evidence-based intervention to reduce the risk of SIDS. The "Back to Sleep" campaign significantly decreased SIDS rates by promoting this practice. Prone or side sleeping increases the risk of airway obstruction and rebreathing of carbon dioxide. Explanation of Incorrect Options: • A. Remove pillows and soft toys from the crib at bedtime: While this is a recommended safe sleep practice, it is not as critical as sleep positioning in preventing SIDS. • B. Keep a bulb syringe accessible for use for an infant: Useful for managing secretions but not directly related to SIDS prevention. • D. Do not prop bottles for an infant during naps and bedtime: Prevents aspiration and ear infections, but does not prevent SIDS specifically. Test-Taking Tip: When the question asks for the most important or priority intervention, choose the one with the strongest evidence tied to the condition—in this case, placing infants on their backs to sleep. DIF: Application REF: Maternal-Child Nursing, Safe Sleep Guidelines (AAP) OBJ: Teach strategies to reduce the risk of SIDS TOP: Newborn and Infant Health Promotion – Safe Sleep ________________________________________ ________________________________________ Question: The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of medication? Options: A. Hypertension B. Difficulty locating the uterine fundus C. Saturation of more than one pad per hour D. Excessive lochia Correct Answer: A. Hypertension Rationale: Methylergonovine maleate (Methergine) is an ergot alkaloid used to stimulate uterine contractions in the management of postpartum hemorrhage caused by uterine atony. However, a major contraindication to its use is hypertension due to its vasoconstrictive properties, which can exacerbate elevated blood pressure and increase the risk for stroke or seizure. If the client becomes hypertensive, the medication should be withheld and the healthcare provider notified. Explanation of Incorrect Options: • B. Difficulty locating the uterine fundus: This indicates uterine atony and is an appropriate indication for methylergonovine—not a reason to withhold it. • C. Saturation of more than one pad per hour: This suggests active bleeding and supports continued uterotonic treatment. • D. Excessive lochia: Also a sign of postpartum hemorrhage, which methylergonovine is meant to treat. Test-Taking Tip: Know contraindications to common medications used in obstetric emergencies. Methylergonovine is effective for atony, but never give it to a hypertensive client. DIF: Application REF: Maternal-Newborn Nursing: The Critical Components of Nursing Care OBJ: Recognize contraindications to uterotonic medications TOP: Postpartum Hemorrhage – Pharmacologic Interventions ________________________________________ ________________________________________ Question: The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take? Options: A. Collect a sputum specimen immediately B. Request a consultation to confirm dysphagia C. Offer the client additional clear liquids frequently D. Encourage the client to do deep breathing exercises daily Correct Answer: B. Request a consultation to confirm dysphagia Rationale: A moist cough that worsens during and after meals is a classic sign of dysphagia and possible aspiration risk. Early identification via speech or swallowing evaluation is critical to prevent complications such as aspiration pneumonia. Referring for a formal dysphagia assessment is the priority nursing action. Explanation of Incorrect Options: • A. Collect a sputum specimen immediately: While aspiration pneumonia may develop, collecting sputum before assessment is premature. • C. Offer the client additional clear liquids frequently: Giving liquids without assessing swallowing ability can increase aspiration risk. • D. Encourage the client to do deep breathing exercises daily: While important for respiratory health, this does not address the immediate risk of aspiration related to dysphagia. Test-Taking Tip: When cough worsens with eating or drinking, suspect swallowing difficulty and prioritize assessment and consultation before interventions. DIF: Application REF: Gerontologic Nursing: Principles and Practice OBJ: Identify signs of dysphagia and appropriate nursing actions TOP: Swallowing Disorders and Aspiration Risk ________________________________________ ________________________________________ Question: A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perineal pain after her last delivery. What action should the nurse implement? Options: A. Use analgesic spray to the perineal area to reduce pain B. Apply an ice pack to the perineum for the first 24 hours C. Teach the client how to practice Kegel exercises D. Review the use of sitz bath equipment with the client Correct Answer: B. Apply an ice pack to the perineum for the first 24 hours Rationale: After vaginal delivery, cold therapy (ice packs) is recommended during the first 24 hours to reduce perineal swelling and pain. Warm sitz baths are typically initiated after the first 24 hours to promote healing and relieve discomfort. The nurse should advise the client to wait before starting warm sitz baths. Explanation of Incorrect Options: • A. Use analgesic spray to the perineal area to reduce pain: While topical analgesics may help, cold therapy remains the first-line intervention immediately postpartum. • C. Teach the client how to practice Kegel exercises: Important for pelvic floor strengthening but not immediately relevant to pain management. • D. Review the use of sitz bath equipment with the client: Premature since warm sitz baths are contraindicated during the first 24 hours postpartum. Test-Taking Tip: Cold therapy is standard for acute postpartum perineal pain and swelling in the first 24 hours; warm therapy follows later for comfort and healing. DIF: Application REF: Maternal-Newborn Nursing: Care During the Postpartum Period OBJ: Implement appropriate postpartum comfort measures TOP: Postpartum Care – Perineal Pain Management ________________________________________ ________________________________________ Question: When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we sought treatment sooner!" Which intervention is best for the nurse to implement? Options: A. Refer the parents to the chaplain to provide grief counseling B. Assure the parents that a terminal diagnosis was inevitable C. Tell the parents that blaming each other will not change the situation D. Explain to the parents that anger is a common response to grief Correct Answer: D. Explain to the parents that anger is a common response to grief Rationale: Anger is a natural and expected stage in the grief process. Helping the parents understand this normal emotional reaction can facilitate coping and promote communication. Validating their feelings and providing emotional support is the nurse’s best immediate intervention. Explanation of Incorrect Options: • A. Refer the parents to the chaplain to provide grief counseling: Appropriate later but does not address the immediate emotional outburst. • B. Assure the parents that a terminal diagnosis was inevitable: This may come across as dismissive and can increase distress. • C. Tell the parents that blaming each other will not change the situation: While true, this may provoke defensiveness and worsen conflict rather than support emotional processing. Test-Taking Tip: In acute grief situations, first acknowledge and normalize emotional responses before moving on to problem-solving or referrals. DIF: Application REF: Palliative and End-of-Life Care Nursing Guidelines OBJ: Manage family emotional responses to terminal illness TOP: Grief and Bereavement – Emotional Support ________________________________________ ________________________________________ Question: The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complementary medical therapies might cure the disease. Which response should the nurse provide? Options: A. Complete a list of alternative medications that are effective in curing Parkinson’s disease B. Explain there are no known conventional, alternative, or complementary therapies that cure Parkinson’s disease C. Encourage the wife to ventilate her feelings about having a husband with Parkinson’s disease D. Tell the wife that her husband’s neurologist just would know more about alternative treatments to cure Parkinson’s Correct Answer: B. Explain there are no known conventional, alternative, or complementary therapies that cure Parkinson’s disease Rationale: Currently, there is no cure for Parkinson’s disease, whether conventional or alternative. Treatments focus on managing symptoms and improving quality of life. The nurse should provide honest, clear information to prevent misconceptions and false hope. Explanation of Incorrect Options: • A. Complete a list of alternative medications: No therapies cure Parkinson’s; listing ineffective treatments may be misleading. • C. Encourage ventilating feelings: Important for emotional support but does not answer the direct question. • D. Refer to neurologist for alternative treatments: While referral is good, the nurse should first provide accurate information about the absence of cures. Test-Taking Tip: When asked about cures for chronic neurodegenerative diseases, focus on realistic expectations and symptom management. DIF: Knowledge REF: Neurology Nursing: Parkinson’s Disease Management OBJ: Communicate realistic expectations about disease treatment TOP: Chronic Neurodegenerative Disorders – Patient Education ________________________________________ ________________________________________ Question: An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? Options: A. 1000, 1600, 2200, 0400 B. 0800, 1200, 1600, 2000 C. Administer with meals and a bedtime snack D. Given equally divided doses during waking hours Correct Answer: D. Given equally divided doses during waking hours Rationale: Administering doses equally spaced during waking hours helps maintain therapeutic drug levels while considering patient safety and comfort. This scheduling avoids unnecessary nocturnal doses that can disrupt sleep, unless the medication requires strict around-the-clock dosing. Explanation of Incorrect Options: • A. 1000, 1600, 2200, 0400: Includes doses during the night (2200, 0400), which may disrupt sleep unless essential. • B. 0800, 1200, 1600, 2000: Unequal spacing between doses (4 hours between and , but only 4 hours to 2000 and then a long gap overnight). • C. Administer with meals and a bedtime snack: IV antibiotics are not typically scheduled based on meals, and bedtime snacks may not align with appropriate dosing intervals. Test-Taking Tip: When given a choice, select a schedule that maintains consistent blood levels with minimal disruption to patient routines unless strict intervals are mandated. DIF: Application REF: Pharmacology for Nurses OBJ: Schedule medication administration for optimal therapeutic effect TOP: Medication Administration – Antibiotic Dosing ________________________________________ ________________________________________ Question: The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? Options: A. Continued development of the brain lesion determines the child's outcome B. Brain damage with CP is not progressive but it does have variable course C. CP is one of the most common permanent physical disabilities in children D. Severe motor dysfunction determines the extent of successful habilitation Correct Answer: B. Brain damage with CP is not progressive but it does have variable course Rationale: Cerebral palsy results from non-progressive brain injury or malformation occurring early in development. The brain damage itself does not worsen over time; however, the symptoms and functional abilities may change due to growth, muscle tone changes, or secondary complications. This explanation helps parents understand that the underlying brain injury is stable. Explanation of Incorrect Options: • A. Continued development of the brain lesion determines the child's outcome: The lesion itself does not progress after the initial injury. • C. CP is one of the most common permanent physical disabilities in children: True, but it does not answer the question about progression. • D. Severe motor dysfunction determines the extent of successful habilitation: While this impacts outcomes, it does not address progression of the brain injury. Test-Taking Tip: Remember that CP is a static encephalopathy — the brain injury is non-progressive, but symptoms can vary. DIF: Knowledge REF: Pediatric Neurology Nursing OBJ: Explain the nature and progression of cerebral palsy TOP: Neurologic Disorders – Cerebral Palsy ________________________________________ ________________________________________ Question: The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? Options: A. Identifies 2 treatments for constipation due to immobility B. Names 3 home safety hazards to be resolved immediately C. States 4 risk factors for the development of osteoporosis D. Lists five calcium-rich foods to be added to her daily diet Correct Answer: B. Names 3 home safety hazards to be resolved immediately Rationale: Osteoporosis leads to fragile bones that are prone to fractures, especially from falls. Preventing falls through home safety modifications is the highest priority because it directly reduces the immediate risk of serious injury. Teaching the client to recognize and eliminate fall hazards (e.g., loose rugs, poor lighting, clutter) is a critical part of injury prevention in osteoporosis care. Explanation of Incorrect Options: • A. Identifies 2 treatments for constipation due to immobility: Important but not the most urgent or safety-focused goal. • C. States 4 risk factors for the development of osteoporosis: Helpful for awareness but does not address immediate safety concerns. • D. Lists five calcium-rich foods to be added to her daily diet: Supports long-term bone health but does not prevent short-term injury risk. Test-Taking Tip: In chronic conditions like osteoporosis, always prioritize safety interventions—especially fall prevention—as the most urgent outcomes. DIF: Analysis REF: Geriatric Nursing and Musculoskeletal Disorders OBJ: Develop a safety-focused teaching plan for osteoporosis TOP: Risk for Injury – Fall Prevention in Osteoporosis ________________________________________ ________________________________________ Question: A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? Options: A. Administer a non-steroidal anti-inflammatory drug for pain B. Check neurovascular status of the distal digits C. Change the dressing if drainage increases D. Position the arm in a sling for discharge Correct Answer: B. Check neurovascular status of the distal digits Rationale: Postoperative assessment for carpal tunnel release must include evaluating neurovascular function to ensure perfusion and sensory/motor integrity. Compartment syndrome or nerve damage can occur and must be identified early. DIF: Application REF: Perioperative Nursing OBJ: Evaluate postoperative complications TOP: Musculoskeletal System – Postoperative Care ________________________________________ Question: An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problem should the nurse include in the client's plan of care? Select all that apply. Options: A. Fluid volume excess B. Decreased cardiac output C. Altered peripheral tissue perfusion D. Fluid volume deficit E. Fatigue Correct Answers: A. Fluid volume excess B. Decreased cardiac output C. Altered peripheral tissue perfusion E. Fatigue Rationale: These nursing diagnoses reflect common complications of HF and CAD, particularly in respiratory distress. Fluid overload and impaired perfusion contribute to fatigue and oxygenation issues. Fluid volume deficit is not typical in this case. DIF: Analysis REF: Cardiovascular Nursing Care Plans OBJ: Develop priority nursing diagnoses TOP: Heart Failure – Nursing Process ________________________________________ Question: The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? Options: A. As the burn heals, the graft permanently attaches B. Grafts are later removed by a debriding procedure C. Grafting increases the risk for bacterial infections D. The xenograft is taken from non-human sources Correct Answer: D. The xenograft is taken from non-human sources Rationale: A xenograft is derived from animals, commonly pigs. For clients with religious or cultural dietary laws, such as observant Jewish clients, this must be disclosed to support informed consent. DIF: Knowledge REF: Burn Care and Cultural Considerations OBJ: Educate clients on graft options TOP: Integumentary – Burns and Cultural Care ________________________________________ ________________________________________ Question: The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child’s anxiety, what action is best for the nurse to implement? Options: A. Provide dolls and equipment to re-enact feelings associated with painful procedures B. Give the child syringes or hospital masks to play with at home prior to hospitalization C. Provide a family tour of the preoperative unit one week before the surgery is scheduled D. Include the child in play therapy with children who are hospitalized for similar surgery Correct Answer: A. Provide dolls and equipment to re-enact feelings associated with painful procedures Rationale: Using medical play with dolls and equipment allows school-age children to express their fears and gain mastery over unfamiliar experiences. This developmental approach to teaching helps reduce anxiety by giving the child control and understanding of what to expect. Explanation of Incorrect Options: • B. Playing with syringes or masks at home without guided explanation may increase fear or confusion. • C. A tour can be helpful, but may be too far in advance to be meaningful or remembered by a child. • D. Group play therapy may not be feasible before surgery and may expose the child to others’ fears or behaviors. Test-Taking Tip: When planning interventions for children, consider the child’s developmental stage. For school-age children, hands-on, concrete, and imaginative strategies that encourage autonomy and expression are most effective. DIF: Application REF: Pediatric Preoperative Teaching Strategies OBJ: Reduce preoperative anxiety in pediatric clients TOP: Pediatric Nursing – Psychosocial Development and Preoperative Care ________________________________________ ________________________________________ Question: A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement? Options: A. Replace the IV site with a smaller gauge B. Apply soft bilateral wrist restraints C. Leave the lights on in the room at night D. Redress the abdominal incision Correct Answer: D. Redress the abdominal incision Rationale: The immediate concern is that the surgical dressing is no longer occlusive, which increases the risk of infection. The nurse should redress the wound to protect the incision and promote healing. This intervention addresses the client's current behavior without escalating to restraint use. Explanation of Incorrect Options: • A. The IV site does not show signs of phlebitis or infiltration (it is pink, not red or swollen), so there's no indication it needs to be changed. • B. Restraints should only be used as a last resort and require a thorough assessment and a provider order. Non-restrictive interventions should be attempted first. • C. Leaving lights on may worsen confusion in clients with dementia and disrupt circadian rhythm. Test-Taking Tip: Always address safety and risk of infection first. Use the least restrictive intervention necessary and reserve restraints for situations when all other strategies have failed. DIF: Application REF: Medical-Surgical Nursing: Patient-Centered Collaborative Care OBJ: Implement safe and appropriate nursing interventions for clients with dementia TOP: Cognitive Disorders – Dementia and Postoperative Care ________________________________________ ________________________________________ Question: A client is experiencing withdrawal from the benzodiazepine alprazolam and is demonstrating severe agitation and tremors. What is the best initial nursing action? Options: A. Administer naloxone per PRN protocol B. Obtain a serum drug screen C. Initiate seizure precautions D. Instruct the family about withdrawal symptoms Correct Answer: C. Initiate seizure precautions Rationale: Benzodiazepine withdrawal, especially from short-acting agents like alprazolam (Xanax), can lead to life-threatening complications such as seizures. Initiating seizure precautions is the best initial nursing action to ensure client safety and prevent injury during a potential seizure. Explanation of Incorrect Options: • A. Naloxone is an opioid antagonist used to reverse opioid overdose, not benzodiazepine withdrawal. It is not appropriate in this context. • B. While a serum drug screen may be useful in a full evaluation, it is not the priority action when the client is actively exhibiting withdrawal symptoms. • D. Educating the family is important, but it is not an immediate or priority nursing action during an acute withdrawal phase. Test-Taking Tip: Always prioritize client safety. With withdrawal syndromes known to cause seizures (e.g., alcohol, benzodiazepines), initiate seizure precautions immediately. DIF: Application REF: Psychiatric Mental Health Nursing, Varcarolis OBJ: Identify priority interventions for clients in withdrawal TOP: Substance Use Disorders – Benzodiazepine Withdrawal ________________________________________ ________________________________________ Question: A client's morning assessment includes bounding peripheral pulses, weight gain of two pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? Options: A. Restrict daily fluid intake to 1500 ml B. Administer prescribed diuretic C. Maintain accurate intake and output D. Weigh client every morning Correct Answer: B. Administer prescribed diuretic Rationale: These findings—bounding pulses, sudden weight gain, dependent edema, and crackles—are classic signs of fluid volume excess, commonly seen in clients with heart failure or renal dysfunction. The most immediate and therapeutic intervention is to administer the prescribed diuretic, which will help reduce intravascular and interstitial fluid volume, alleviate pulmonary congestion, and improve breathing and perfusion. Explanation of Incorrect Options: • A. Fluid restriction may be needed, but it does not address the existing excess fluid as rapidly as a diuretic does. • C. Monitoring intake and output is essential but is more of a supportive measure, not a therapeutic one. • D. Daily weights are important to assess fluid status trends, but they are a monitoring intervention, not an immediate treatment. Test-Taking Tip: When multiple answers are correct, prioritize the most immediate and therapeutic intervention—especially when symptoms indicate acute decompensation. DIF: Application REF: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (Lewis et al.) OBJ: Implement appropriate interventions for fluid volume excess TOP: Fluid and Electrolyte Imbalance – Fluid Volume Excess ________________________________________ ________________________________________ Question: The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time? Options: A. Risk for infection B. Impaired physical mobility C. Self-care deficit D. Risk for impaired skin integrity Correct Answer: A. Risk for infection ________________________________________ Rationale: Clients with peripheral neuropathy often lose protective sensation in the feet, making them prone to unnoticed injuries, poor wound healing, and subsequent infections. Since neuropathy can mask symptoms of cuts, blisters, or ulcers, the risk for infection is the most critical concern when planning foot care. Prompt identification and intervention can prevent complications such as cellulitis or osteomyelitis. ________________________________________ Explanation of Incorrect Options: • B. Impaired physical mobility – While neuropathy may affect mobility, it is not the immediate priority when addressing foot care. • C. Self-care deficit – May be relevant if the client cannot perform foot care, but infection prevention takes precedence. • D. Risk for impaired skin integrity – Also applicable, but infection poses the more urgent and potentially life-threatening consequence. ________________________________________ Test-Taking Tip: Prioritize physiological risks that can lead to severe complications—infection from unnoticed injury in neuropathic clients is a high-priority concern. ________________________________________ DIF: Application REF: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing OBJ: Implement nursing interventions to prevent complications of peripheral neuropathy TOP: Neurologic Disorders – Peripheral Neuropathy – Foot Care ________________________________________ Question: The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? Options: A. Prepare the client for spinal anesthesia B. Prepare the coach to accompany the client to delivery C. Empty the client's bladder using a straight catheter D. Convey to the client that birth is imminent Correct Answer: D. Convey to the client that birth is imminent ________________________________________ Rationale: The second stage of labor begins with complete cervical dilation (10 cm) and ends with the birth of the baby. It is essential to provide reassurance and guidance as the client enters this stage, including informing them that birth is near. This helps reduce anxiety, enhances cooperation, and promotes effective pushing. Communicating the imminence of delivery supports psychological preparation and readiness. ________________________________________ Explanation of Incorrect Options: • A. Prepare the client for spinal anesthesia – Regional anesthesia is typically administered in the first stage of labor; it is not initiated during the second stage when delivery is imminent. • B. Prepare the coach to accompany the client to delivery – While supportive, it is not the priority for the client’s immediate needs during this critical phase. • C. Empty the client's bladder using a straight catheter – This may be done earlier in labor to promote fetal descent, but the urgency of imminent birth takes precedence. ________________________________________ Test-Taking Tip: In the second stage of labor, prioritize communication and interventions that support immediate preparation for delivery. Look for cues indicating urgency or physiological transition. ________________________________________ DIF: Application REF: Lowdermilk’s Maternity and Women’s Health Care OBJ: Identify nursing care during the second stage of labor TOP: Intrapartum Care – Labor and Birth Process ________________________________________ Question: A client with cirrhosis of the liver is having numerous liquid incontinent stools and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? Options: A. Furosemide B. Lactulose C. Loperamide D. IV human albumin Correct Answer: B. Lactulose ________________________________________ Rationale: Lactulose is a non-absorbable disaccharide laxative that promotes the excretion of ammonia in clients with hepatic encephalopathy, a complication of liver cirrhosis. Elevated serum ammonia contributes to confusion and altered mental status. Lactulose acidifies the colon and converts ammonia (NH₃) to ammonium (NH₄⁺), which is then excreted in the stool, helping reduce serum ammonia levels and improve neurologic symptoms. ________________________________________ Explanation of Incorrect Options: • A. Furosemide – A loop diuretic that may help with fluid retention in cirrhosis, but it does not address elevated ammonia levels or encephalopathy directly. • C. Loperamide – An antidiarrheal that would counteract lactulose’s desired effect of increased bowel movements to eliminate ammonia. • D. IV human albumin – Used to manage hypoalbuminemia or fluid shifts, but not effective for reducing ammonia levels or treating encephalopathy. ________________________________________ Test-Taking Tip: In clients with liver failure and signs of hepatic encephalopathy (e.g., confusion, high ammonia), Lactulose is the first-line treatment. Don’t be misled by diarrhea; that’s an expected therapeutic effect. ________________________________________ DIF: Application REF: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing OBJ: Implement therapeutic interventions for clients with hepatic encephalopathy TOP: Gastrointestinal Disorders – Cirrhosis – Hepatic Encephalopathy After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next? a. Note the presence of an auscultatory gap b. Reinflate the cuff to a higher number c. Reposition the stethoscope over the brachial artery d. Continue with the blood pressure assessment d. Continue with the blood pressure assessment Correct Answer: D. Continue with the blood pressure assessment ________________________________________ Rationale: The auscultatory gap is a normal phenomenon that can occur in some individuals during blood pressure measurement, particularly in those with hypertension or arterial stiffness. It refers to a temporary disappearance of Korotkoff sounds after the initial systolic sound, followed by their reappearance at a lower pressure. If the nurse hears silence followed by a Korotkoff sound after releasing the valve, this may indicate an auscultatory gap, but it does not warrant stopping or restarting the reading. The nurse should continue with the blood pressure assessment to obtain accurate systolic and diastolic values. ________________________________________ Explanation of Incorrect Options: • A. Note the presence of an auscultatory gap – While recognizing an auscultatory gap is clinically relevant, this is not the next action; continuing the assessment ensures full and accurate blood pressure measurement. • B. Reinflate the cuff to a higher number – This can be harmful if done after deflation, potentially causing pain or vascular injury. The cuff should not be reinflated without fully deflating and allowing time between attempts. • C. Reposition the stethoscope over the brachial artery – Repositioning is only needed if no sounds are heard at all or if placement is in question. In this scenario, Korotkoff sounds are heard, so there's no need to move the stethoscope. ________________________________________ Test-Taking Tip: Don't be distracted by technical terms like "auscultatory gap." Focus on what the nurse should do next based on what is heard—if Korotkoff sounds are present, continue the assessment. ________________________________________ DIF: Application REF: Fundamentals of Nursing (Potter & Perry) OBJ: Perform accurate blood pressure measurements TOP: Vital Signs – Blood Pressure Assessment Correct Answer: C. Anxiety ________________________________________ Rationale: The client's emotional response—crying and expressing fear of pain—indicates a high level of anxiety about the upcoming surgery and pain management. Anxiety is the priority nursing problem in this situation because it can interfere with the client’s ability to process information, participate in preoperative teaching, and cope effectively with the surgical experience. Addressing anxiety first allows the nurse to provide emotional support and reassess the client's ability to understand and retain information about pain management. ________________________________________ Explanation of Incorrect Options: • A. Anticipatory grieving – This diagnosis involves mourning a perceived future loss, such as death or body image. The client's concern is focused on pain, not loss. • B. Pain (acute) – The client is not currently in pain. The concern is about future pain after surgery, so this diagnosis does not apply yet. • D. Knowledge deficit – While the client may lack knowledge, anxiety is likely blocking their ability to absorb or retain new information. The emotional response must be managed before education can be effective. ________________________________________ DIF: Analysis REF: Fundamentals of Nursing (Potter & Perry) OBJ: Prioritize nursing diagnoses based on client assessment TOP: Preoperative Care – Psychosocial Needs A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately? a. Administer IV atropine b. Defibrillate with one shock c. Give a dose of amiodarone IV d. Prepare for external pacing b. Defibrillate with one shock Correct Answer: B. Defibrillate with one shock ________________________________________ Rationale: Ventricular fibrillation (VF) is a life-threatening cardiac arrest rhythm that results in no effective cardiac output. The immediate and priority intervention is defibrillation—delivering a high-energy shock to reset the heart’s electrical system and restore a perfusing rhythm. Early defibrillation is the most effective treatment for VF and improves chances of survival dramatically. ________________________________________ Explanation of Incorrect Options: • A. Administer IV atropine – Atropine is used for bradycardia, not for VF. It has no role in the management of ventricular fibrillation. • C. Give a dose of amiodarone IV – Amiodarone is used after defibrillation and CPR have been initiated and if VF is refractory (persists after multiple shocks), not as the first action. • D. Prepare for external pacing – Pacing is used for bradyarrhythmias, not for pulseless rhythms like VF. External pacing is not effective during VF. ________________________________________ DIF: Analysis REF: Advanced Cardiovascular Life Support (ACLS) Guidelines OBJ: Manage cardiac arrest and life-threatening arrhythmias TOP: Emergency Cardiac Care – Ventricular Fibrillation Test-Taking Tip: For pulseless ventricular rhythms (like VF and pulseless VT), think "shock first". Always prioritize defibrillation over drug administration. Question: A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the new nurse prepare to administer a unit of packed red blood cells as seen in the picture. Which action should the charge nurse take? Options: A. Verify that a 22-gauge intravenous catheter is used for the transfusion B. Assist the nurse in changing the intravenous tubing attached to the blood C. Tell the nurse to take the client’s vital signs and then start the transfusion D. Assume responsibility for the care of the client during the blood transfusion Correct Answer: B. Assist the nurse in changing the intravenous tubing attached to the blood ________________________________________ Rationale: Blood products must be administered with Y-tubing specifically designed for blood transfusion, which includes a filter and 0.9% normal saline (NS) as the only compatible fluid. If the tubing is not appropriate (e.g., primary IV tubing or tubing used for other medications or fluids), it must be changed before initiating the transfusion to prevent hemolysis, clotting, or reaction. The charge nurse should assist in correcting this critical step and use the opportunity as a teachable moment during orientation. ________________________________________ Explanation of Incorrect Options: • A. Verify that a 22-gauge intravenous catheter is used for the transfusion A 22-gauge catheter may be acceptable, especially in older adults or those with fragile veins, but 16–20 gauge is preferred for rapid transfusion. This is not the most immediate concern if incorrect tubing is used. • C. Tell the nurse to take the client’s vital signs and then start the transfusion Taking vital signs is part of transfusion protocol, but starting the transfusion with improper tubing is unsafe. This action ignores the tubing error. • D. Assume responsibility for the care of the client during the blood transfusion While client safety is paramount, the better option is to supervise and educate the new nurse rather than remove the learning opportunity. This fosters professional growth and ensures safe practice. ________________________________________ Test-Taking Tip: In situations involving new or novice nurses, prioritize teaching and safety. When a procedure is incorrect or unsafe, correct the action and provide instruction—this supports both the patient and the learner. ________________________________________ DIF: Application REF: Fundamentals of Nursing, Blood Administration Protocols OBJ: Safe Medication and Fluid Administration TOP: Blood Transfusion Safety Question: The home care nurse visits a client who has cancer. The client reports having a good appetite but experiences nausea when smelling food cooking. What action should the nurse implement? Options: a. Encourage family members to cook meals outdoors and bring the cooked foods inside b. Advise the client to replace cooked foods with a variety of different nutritional supplements c. Assess the client's mucous membranes and report the findings to the health care provider d. Instruct the client to take an anti-emetic before every meal to prevent excessive vomiting Correct Answer: a. Encourage family members to cook meals outdoors and bring the cooked foods inside ________________________________________ Rationale: Cancer treatments (e.g., chemotherapy or radiation) often cause nausea and heightened sensitivity to odors, especially while food is being prepared. A client who has appetite but nausea from cooking smells would benefit from environmental strategies to reduce exposure to strong odors. Cooking outdoors or having meals prepared away from the client and then brought in helps preserve appetite without triggering nausea. ________________________________________ Explanation of Incorrect Options: • b. Advise the client to replace cooked foods with a variety of different nutritional supplements While supplements can help meet nutritional needs, this client still has a good appetite, and switching entirely to supplements isn't necessary or ideal. • c. Assess the client's mucous membranes and report the findings to the health care provider This may be appropriate for clients with oral complications or poor intake, but in this scenario, the issue is odor-triggered nausea, not mucosal integrity. • d. Instruct the client to take an anti-emetic before every meal to prevent excessive vomiting The client isn’t reporting vomiting, and prophylactic medication may be unnecessary and inappropriate unless prescribed. Non-pharmacologic interventions should be tried first. ________________________________________ Test-Taking Tip: When the client tolerates food but struggles with a modifiable trigger (like smells), always consider non-pharmacologic, environment-based strategies before recommending medication or major dietary changes. ________________________________________ DIF: Application REF: Ignatavicius: Medical-Surgical Nursing, 10th ed., Cancer Management OBJ: Manage nutrition and symptom control in cancer patients TOP: Supportive Care – Nausea Management in Oncology Clients Question: The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement? Options: a. Advise the UAP to document the last blood pressure obtained in the client's graphic sheet b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed c. Document why the blood pressure cannot be accurately measured at the present time d. Estimate the blood pressure by assessing the pulse volume of the clients' radial pulses Correct Answer: b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed ________________________________________ Rationale: When both arms are inaccessible for blood pressure measurement due to casts, and the client cannot be positioned prone for leg BP, the next best option is to measure the BP using the popliteal artery with the client in a supine position and knee slightly flexed. This allows for an accurate measurement of BP without turning the client. Demonstrating this technique ensures the UAP can obtain a reliable reading using an alternative site. ________________________________________ Explanation of Incorrect Options: • a. Advise the UAP to document the last blood pressure obtained in the client's graphic sheet This does not address the need for a current blood pressure, which is a critical vital sign. • c. Document why the blood pressure cannot be accurately measured at the present time This might be necessary after all other methods have failed. However, an alternative site (popliteal) is available and should be used. • d. Estimate the blood pressure by assessing the pulse volume of the clients' radial pulses Pulse volume is not a reliable substitute for BP measurement. Estimating BP based on pulse quality is inaccurate and unsafe. ________________________________________ DIF: Application REF: Potter & Perry: Fundamentals of Nursing, 11th ed., Chapter 30 – Vital Signs OBJ: Perform accurate blood pressure assessments using alternative sites TOP: Vital Sign Assessment – Blood Pressure Measurement Alternatives Question: The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? Options: a. A young man with schizophrenia who wants to stop taking his medications b. The mother of a child who was involved in a physical fight at school today c. A client diagnosed with depression who is experiencing sexual dysfunction d. A family member of a client with dementia who has been missing for five hours Correct Answer: d. A family member of a client with dementia who has been missing for five hours ________________________________________ Rationale: The highest priority in this scenario is client safety. A client with dementia who has been missing for five hours is at immediate risk for injury, exposure, or death, especially if they have impaired judgment, memory, or orientation. Wandering is a well-known high-risk behavior in clients with dementia, and delays in locating the person can have life-threatening consequences. ________________________________________ Explanation of Other Options: • a. A young man with schizophrenia who wants to stop taking his medications This is important, as noncompliance can lead to relapse, but it is not as urgent as locating a missing person at immediate risk. • b. The mother of a child who was involved in a physical fight at school today This warrants follow-up, especially to assess for trauma or behavioral issues, but it does not pose immediate danger. • c. A client diagnosed with depression who is experiencing sexual dysfunction This is a quality-of-life concern and is a common side effect of antidepressants, but it is not emergent. ________________________________________ DIF: Analysis REF: Varcarolis, Essentials of Psychiatric Mental Health Nursing, 4th ed., Chapter 23 – Neurocognitive Disorders OBJ: Prioritize care based on client safety TOP: Risk for Injury – Dementia/Wandering Behavior Question: A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? Options: a. Chemotherapy b. Immunosuppressive therapy c. Blood transfusions d. Bone marrow transplantation Correct Answer: d. Bone marrow transplantation Rationale: Bone marrow transplantation (BMT) offers the best chance for cure in children with acquired aplastic anemia, especially when a matched donor is available. BMT replaces the damaged bone marrow with healthy stem cells, restoring normal blood cell production. Explanation of Other Options: a. Chemotherapy Chemotherapy is not a treatment for aplastic anemia and may worsen bone marrow suppression. b. Immunosuppressive therapy Immunosuppressive therapy can be effective in patients without a suitable donor but generally provides a less definitive outcome than BMT. c. Blood transfusions Blood transfusions provide supportive care by temporarily managing anemia or thrombocytopenia but do not treat the underlying marrow failure or provide a cure. DIF: Application REF: Lewis et al., Medical-Surgical Nursing, 11th ed., Chapter on Hematologic Disorders OBJ: Identify best treatment options for acquired aplastic anemia TOP: Bone marrow transplantation – Curative therapy for aplastic anemia ________________________________________ Question: A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible? Options: A. Teach the client about the side effects of the prescribed anti-infective drug B. Assess the last 24-hour oral and intravenous fluid