EXAM QUESTIONS WITH DETAILED VERIFIED
ANSWERS (100% CORRECT ANSWERS) /ALREADY GRADED A+!!.
NCLEX 2025.
The nurse has attended a staff education program about caring for clients who
are receiving positive pressure mechanical ventilation. Which of the following
statements by the nurse would indicate a correct understanding of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned
from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria." - - ANS - -2. "Clients may
develop stress ulcers and gastrointestinal bleeding."
,Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding
because
The charge nurse must transfer a female client from the medical-surgical unit to
the maternity unit to make a bed available. It would be most appropriate for the
nurse to transfer the client who is
1. 28 years old, had a right mastectomy and has a closed-wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an external fixation device
applied 48 hours ago - - ANS - -3. 56 years old, has hepatitis C (HCV) and has
been afebrile for 24 hours
The nurse has been made aware of the following client situations. The nurse
should first assess the client with:
1. heart failure who has a productive cough and is anxious
2. regional enteritis (Crohn's disease) who is reporting cramping abdominal pain
and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and
is reporting heavy menses
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion
and is using accessory muscles to breathe - - ANS - -1. heart failure who has a
productive cough and is anxious
Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might
be caused by decreased perfusion
,The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following tasks would be appropriate for the nurse to assign to
UAP?
1. assisting a client with atrial fibrillation to shower
2. checking the ability of a client to swallow water after a
transesophageal echocardiogram (TEE)
3. observing while a client with dysphagia begins a thickened liquid diet
4. transporting a client with respiratory distress to the radiology department
for a chest radiograph - - ANS - -1. assisting a client with atrial fibrillation to
shower
UAP can perform hygiene
Rationale:
Only nurses can assess. Transporting a client in respiratory arrest is not safe to
delegate to a UAP
The nurse has taken a nutritional history from parents of clients. It would be a
priority for the nurse to follow up with the
1. 5-month-old client whose only source of nutrition is 5 formula feedings daily
2. 7-month-old client who eats several crackers as finger food
3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1
cup of apple juice, and 3 servings of infant cereal
4. 1-year-old client whose typical food intake includes 4 breast-feedings and 3
servings of cooked vegetables, pears, or sliced cheese - - ANS - -3. 9-month-
old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple
juice, and 3 servings of infant cereal
, Rationale: Cows milk should be introduced at 12 months old. It doesn't provide
the necessary nutrients and baby can develop iron deficiency
The nurse is planning a staff education program about client privacy. Which of
the following scenarios should the nurse include as an example of a violation
of client privacy?
1. discussing with an unlicensed assistive personnel (UAP) that the UAP's
assigned client will require a smaller condom catheter
2. sharing the client's blood alcohol level (BAL) test result with the police officer
who brought the client to the emergency department (ED)
3. responding to the call light of the client who is assigned to another nurse
and needs assistance in the bathroom
4. allowing a nursing student who has been assigned to the client to review the
client's medical record - - ANS - -2. sharing the client's blood alcohol level (BAL)
test result with the police officer who brought the client to the emergency
department (ED)
Rationale: PHI is permitted to be disclosed to police when PHI is needed to
apprehend the perpetrator of a violent crime, suspect, or fugitive.
The nurse has become aware of the following client situations. The nurse should
first assess the client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's
position while lying on the right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-
lip breathing and reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the
high- Fowler's position