QUESTIONS AND VERIFIED ANSWERS ||
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LATEST UPDATE 2025
The nurse is assessing a client 2 hours postoperatively after a femoral popliteal
bypass. The upper leg dressing becomes saturated with blood. The nurse's first
action should be to
A) Wrap the leg with elastic bandages
B) Apply pressure at the bleeding site
C) Reinforce the dressing and elevate the leg
D) Remove the dressings and re-dress the incision - ANSWER- C: Reinforce
the dressing and elevate the leg
A client is receiving external beam radiation to the mediastinum for treatment of
bronchial cancer. Which of the following should take priority in planning care?
A) Esophagitis
B) Leukopenia
C) Fatigue
D) Skin irritation - ANSWER- B: Leukopenia
A client has a chest tube in place following a left lower lobectomy inserted after
a stab wound to the chest. When repositioning the client, the nurse notices 200
cc of dark, red fluid flows into the collection chamber of the chest drain. What
is the most appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
,C) Prepare for blood transfusion
D) Continue to monitor the rate of drainage - ANSWER D: Continue to monitor
the rate of drainage
The nurse is teaching the client to select foods rich in potassium to help prevent
digitalis toxicity. Which choice indicates the client understands dietary needs?
A) Three apricots
B) Medium banana
C) Naval orange
D) Baked potato - ANSWER D: Baked potato.
An 86 year-old nursing home resident who has decreased mental status is
hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse
assists the client with a clear liquid diet, the client begins to cough. What should
the nurse do next?
A) Add a thickening agent to the fluids
B) Check the client's gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids - ANSWER- B: Check the client's gag
reflex
The nurse is planning care for a client with a CVA. Which of the following
measures planned by the nurse would be most effective in preventing skin
breakdown?
A) Place client in the wheelchair for four hours each day
B) Pad the bony prominence
C) Reposition every two hours
D) Massage reddened bony prominence - ANSWER- C: Reposition every two
hours
,A nurse is assessing several clients in a long term health care facility. Which
client is at highest risk for development of decubitus ulcers?
A) A 79 year-old malnourished client on bed rest
B) An obese client who uses a wheelchair
C) A client who had 3 incontinent diarrhea stools
D) An 80 year-old ambulatory diabetic client - ANSWER- A: A 79 year-old
malnourished client on bed rest
When caring for a client with a post right thoracotomy who has undergone an
upper lobectomy, the nurse focuses on pain management to promote
A) Relaxation and sleep
B) Deep breathing and coughing
C) Incisional healing
D) Range of motion exercises - ANSWER- B: Deep breathing and coughing
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a
client. Which action should the nurse take first? A) Ask client to cough
sputum into container
B) Have the client take several deep breaths
C) Provide a appropriate specimen container
D) Assist with oral hygiene - ANSWER- D: Assist with oral hygiene
A client has returned from a cardiac catheterization. Which one of the following
assessments would indicate the client is experiencing a complication from the
procedure?
A) Increased blood pressure
B) Increased heart rate
, C) Loss of pulse in the extremity
D) Decreased urine output - ANSWER- C: Loss of pulse in the extremity
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He
is awake and alert, but has not been able to void since he returned from surgery
6 hours ago. He received 1000 mL of IV fluid. Which action would be most
likely to help him void?
A) Have him drink several glasses of water
B) Crede' the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again - ANSWER- C: Assist him to
stand by the side of the bed to void
The nurse is caring for a child immediately after surgical correction of a
ventricular septal defect. Which of the following nursing assessments should be
a priority?
A) Blanch nail beds for color and refill
B) Assess for post operative arrhythmias
C) Auscultate for pulmonary congestion
D) Monitor equality of peripheral pulses - ANSWER- B: Assess for post
operative arrhythmias
A client has a history of chronic obstructive pulmonary disease (COPD). As the
nurse enters the client's room, his oxygen is running at 6 liters per minute, his
color is flushed and his respirations are 8 per minute. What should the nurse do
first?
A) Obtain a 12-lead EKG
B) Place client in high Fowler's position
C) Lower the oxygen rate
D) Take baseline vital signs - ANSWER- C: Lower the oxygen rate