AND ANSWERS
To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose
of deep palpation is to assess which of the following? - ANS Correct Answer: Organs
The purpose of deep palpation, in which the nurse indents the client's skin approximately 1-
1/2", is to assess underlying organs and structures such as the kidneys and spleen. Skin turgor,
hydration, and temperature can be assessed using light touch or light palpation.
A client is brought to the emergency department and the physician determines he has
gastrointestinal (GI) bleeding. In planning for his care, which of the following would be first
priority? - ANS The Correct answer is: assessment of vital signs Vital sign assessment would
be the priority nursing intervention. This would provide an indication of the amount of blood
loss that has occurred and also provide a baseline by which to monitor the progress of
treatment. The other answers (b, c, and d) are important but not priority actions.
When providing instructions to the adolescent regarding physical development of her body, the
RN should do all of the following EXCEPT - ANS Correct Answer: Discuss the importance of
avoiding social events in order to stay out of trouble.
Socialization is very important to teenagers and is a normal part of their development. The
other answers (b, c, and d) are all accurate instructions and discussions for the adolescent
regarding development.
The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate
1
the client will be discharged home with home health nursing care. The nurse provides the home
Page
health agency with details regarding the needs of the patient. The nurse made which of the
@COPYRIGHT SIRJOEL 2025/2026
, following to the home health agency? - ANS Correct answer: A referral. A referral is
recommending home care services or giving information to an home care service regarding the
client and the client's needs. Typically the sources of referral to a home care agency are family
members, nurses, physicians, social workers, discharge planners or therapists.
Which of the following is the normal serum electrolyte level for magnesium? - ANS Correct
answer: 1.6 to 2.4 mEq/L
The school nurse is approached by a mother who explains that her kindergarten child is
constantly scratching the perianal area and that the area is irritated. The RN understands that
she should instruct the mother to obtain a rectal specimen by a tape test and that the mother
should obtain the specimen when? - ANS The Correct answer is: in the morning, when the
child awakens Visualization of pinworms by means of a tape test is necessary for the diagnosis.
Transparent tape is lightly touched to the anus and then applied to a slide for microscopic
examination. The best specimen is obtained as the child awakens, before toileting or bathing.
A 20-year-old patient is admitted to the hospital with respiratory failure. He's intubated, given
oxygen, and is coughing with copious secretions in his lungs. What should be done first? -
ANS Correct Answer: Suction the lungs
The first priority is to make sure the client's airways are clear and that he can breathe. The
other choices can be addressed after ensuring the client can breathe.
A high school student is referred to the school nurse for suspected substance abuse. Following
the nurse's assessment and intervention, what would be the MOST desirable outcome? -
ANS Correct Answer: The student accepts a referral to a substance abuse counselor. All of
the outcomes stated are desirable; however, the best outcome is that the student would agree
to seek the assistance of a professional substance abuse counselor.
The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the
physician for the client with seizures. Which of the following solutions will the nurse use to
dilute this medication? - ANS Normal saline (0.9%) solution. Phenytoin (Dilantin) should be
2
administered by injection into a large vein by intermittent intravenous infusion. Normal saline
Page
@COPYRIGHT SIRJOEL 2025/2026
, (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication
precipitation.
Which of the following terms corresponds with the phrase: a woman that is pregnant? -
ANS Gravida
Gravida is another word for pregnancy. Spermatogonia refers to male sperm cells. Placenta
previa is when the placenta is too close to the cervix.
A healthy first time pregnant client asks the nurse, "How long will I stay in the hospital after my
baby is born." The client is scheduled for a Caesarean section. The nurse understands the
average timeframe for the hospital stay for a Caesarean section is what? - ANS Correct
Answer: 72 hours. The hospital stay for a healthy mother who has delivered an infant varies
depending on the type of delivery. The length of stay in the hospital for a vaginal birth is
typically 24 to 48 hours. The length of stay in the hospital for a Caesarean section that does not
have any complications is 72 hours.
The community nurse is planning a smoking cessation program. What would be the first step in
developing a health promotion program? - ANS Correct Answer: Conducting health risk
surveys
First conduct initial assessments to determine if there is a health risk. Then follow the course of
action in place in this event.
A woman is two months pregnant when her five-year-old child develops rubella. What is most
likely to be given to the mother? - ANS Correct Answer: Immune serum globulin
Immune serum globulin gives her a passive immunity and helps keep her from developing
rubella, which can have devastating effect on her unborn child. MMR is a live virus and is not
given to pregnant women. RhoGam prevents anti Rh antibody development. There is no such
thing as rubella antitoxin.
What is the normal value of urine potassium? - ANS 25-120 mEq/24 hr
3
The normal value for urine potassium is 25-120 mEq/24 hr
Page
@COPYRIGHT SIRJOEL 2025/2026