2025 ACTUAL EXAM COMPLETE 100
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS)
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A client with a productive cough has obtained a sputum specimen for culture
as instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab of - ANSWER-B. Observe the color,
consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with
cardiopulmonary resuscitation (CPR) in progress. The client is intubated and
is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines
that the client is cyanotic, cold, and diaphoretic. Which assessment is most
important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
,D. Core body temperature - ANSWER-A. Breath sounds over bilateral lung
fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone
(SIADH), a client develops pontine myelinolysis. Which intervention should the
nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises - ANSWER-A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot
put his shoes on because they are too tight. Which additional information
should the nurse obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - ANSWER-B. Has his weight
changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary
disease (COPD) is admitted with progressive shortness of breath and a
persistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
,C. Apply a high-flow venturi mask
D. Assist her to an upright position - ANSWER-D. Assist her to an upright
position
A client with a history of asthma and bronchitis arrives at the clinic with
shortness of breath, productive cough with thickened tenacious mucous, and
the inability to walk up a flight of stairs without experiencing breathlessness.
Which action is most important for the nurse to instruct the client about self-
care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation - ANSWER-A.
Increase the daily intake of oral fluids to liquefy secretions
A cardiac catheterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal
circumflex, and? % proximal right coronary artery (RCA). The client later asks
the nurse "what does all this mean for me?" What information should the nurse
provide?
A. Blood supply to the heart is diminished by atherosclerotic lesions, which
necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have blockages indicating a
past heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow
getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart failure
and fluid retention. - ANSWER-C. Three main arteries have major blockages,
with only 1 to 5% of blood flow getting through to the heart muscle.
, A client who weighs 175 pounds is receiving IV bolus dose of heparin 80
units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How
many ml should the nurse administer? (Enter numeric value only. If rounding
is required, round to the nearest tenth.) - ANSWER-0.6 ml
What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs - ANSWER-C. Minimize
symptoms by wearing loose, comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which
position should the nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest - ANSWER-A. left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and
is unable to eat or drink without becoming nauseated and vomiting. Which
finding should the nurse report to the healthcare provider.
A. Belching
B. Amber urine