CORRECT DETAILED ANSWERS,A COMPLETE SOLUTION THAT
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1. An older adult male who is in his early 70's is admitted to the emergency department
because of a COPD exacerbation. This client is struggling to breathe and the healthcare team
is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than
the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's
living will. Which action should the nurse take? - CORRECT ANSWERS b. Notify the
healthcare provider of the client's wishes.
2. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and
the mother reports that the child frequently scratches the lesions on the skin to the point of
causing bleeding. Which guideline is indicated for care of this child? - CORRECT ANSWERS b.
Apply baby lotion to the skin twice daily.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on
room air of 89%. Which action should the nurse take first? - CORRECT ANSWERS c. Begin
supplemental oxygen.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply) - CORRECT ANSWERS Headache and
tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment
finding is the best indicator of hydration that the nurse should report to the healthcare
provider? - CORRECT ANSWERS d. Skin tenting occurs when the client's forearm is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding client
information, the nurse observes a colleague going home with printed copies of client
information in a uniform pocket. Which action should the nurse take? - CORRECT ANSWERS
a. File a detailed incident report with the specific hiring facility.
,7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular
disease implemented in a rural health clinic. Which outcome indicate the program is
effective? - CORRECT ANSWERS c. Clients who incurred disease complications promptly
received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client
is having increased shortness of breath with respirations at 23 breaths/minute. Which action
should the nurse implement first? - CORRECT ANSWERS d. Assess the delivery mechanism
of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an
immediate investigation by the nurse? - CORRECT ANSWERS When I get out of bed quickly, I
feel a little dizzy."
10. A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour
IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction
canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg.
In addition to reporting the finding to the surgeon. Which action should the nurse
implement first? - CORRECT ANSWERS d. Increase the infusion rate of Lactated Ringer's
solution.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client
whose prescribed activity is bedrest with bedside commode use. The UAP reports to the
nurse that the client is so obese that the UAP feels unable to safely assist the client in
transferring from the bed to the bedside commode. How should the nurse respond? -
CORRECT ANSWERS c. Advice the client to maintain bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the students at a middle school are
overweight. The nurse presents the information at the parent-teacher meeting. What action
is most important for the nurse to include in the meeting? - CORRECT ANSWERS c.
Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone.
Which education should the nurse provide the client with regard to taking prednisone? -
CORRECT ANSWERS c. If sequential doses are missed, notify the healthcare provider.
, 14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse's immediate attention? - CORRECT ANSWERS c. An 18-year-old client with antisocial
behavior who is being yelled at by other clients
15. The dnurse dcaring dfor da dchild dwith dmononucleosis dcan dexpect dthe dchild dto dexhibit
dwhich dsymptoms? d- d dCORRECT dANSWERS d db. dEar dpain dand dfever.
16. dA dclient darrives dfor dan dannual dphysical dexam dand dcomplains dof dhaving dcalf dpain.
dThe dclient's dhealth dhistory dreveals dperipheral datrial ddisease. dWhich dquestion dshould
dthe dnurse dask dthe dclient dabout dexpected dfinding drelated dto dchronic darterial
dsymptoms? d- d dCORRECT dANSWERS d db. dDoes dthe dcalf dpain doccur dwhen dwalking dshort
ddistances?
17. dThe dnurse dis dpreparing dto dsend da dclient dto dthe dcardiac dcatheterization dlab dfor dan
dangioplasty. dWhich dclient dreport dis dmost dimportant dfor dthem dto dexplore dfurther dprior
dto dthe dstart dof dthe dprocedure? d- d dCORRECT dANSWERS d dd. dExperience dfacial dswelling
dafter deating dcrab.
18. dan dadult dmale dwho dfell d20 dfeet dfrom dthe droof dof dthis dhome dhas dmultiple
dinjuries, dincluding da dright dpneumothorax. dChest dtubes dwere dinserted din dthe
demergency ddepartment dprior dto dhis dtransfer dto dthe dintensive dcare dunit d(ICU). dthe
dnurse dnotes dthat dthe dsuction dcontrol dchamber dis dbubbling dat dthe
- d10 dcm dH2O dmark, dwith dfluctuation din dthe dwater dseal, dand dover dthe dpast dhour d75
dml dof dbright dred dblood dis dmeasured din dthe dcollection dchamber. dWhich dintervention
dshould dthe dnurse dimplement? d- d dCORRECT dANSWERS d da. dAdd dsterile dwater dto dthe
dsuction dcontrol dchamber.
19. dA dnew dmother don dthe dpostpartum dunit druns dout dof dthe droom dscreaming dthat
dher dnewborn dinfant's dcrib dis dempty dand dthe dbaby dis dmissing. dWhat daction dshould
dthe dnurse dtake dfirst? d- d dCORRECT dANSWERS d dd. dMatch dID dbands dof dall dinfants dand
dmothers don dthe dunit.
20. dWhile dproviding da dhealth dhistory, da dfemale dclient dtells dthe dclinic dnurse dthat dshe
dfrequently dthinks dabout dhurting dherself. dWhich dquestion dis dmost dimportant dfor dthe
dnurse dto dask? d- d dCORRECT dANSWERS d dc. d"Have dyou dthought dabout dtaking dyour dlife?"