Answers| LATEST, 2025/2026|With Correct Answers &
Rationale
1. A nurse in a long-term care facility is assisting with an inservice for newly hired
assistive personnel about legal issues within the facility. Which of the following should
the nurse include as an example of assault?
ANS: Informing a client the nurse is going to administer an injection even though the client
refuses
2. A nurse is collecting data from those who are in severe pain. Which of The following
questions should the nurse ask first?
ANS: "Where is your pain located?"
3. A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation.
For which of the following results should the nurse notify the provider?
ANS: Platelet count 95,000 mm3
4. A nurse is performing a dressing change for a client who had abdominal surgery 5
days ago. The nurse notes organs protruding from the incision. Which ofIthe following
actions should the nurse take?
ANS: Cover the exposed area with sterile, saline-soaked Dressings.
5. A nurse is speaking with the adult daughter of a client who has Alzheimer's disease.
The daughter states, "I love my dad, but caring for him is wearing me out." Which of the
following responses should the nurse make?
ANS: "Let's discuss how caring for your father is affecting your health.
6. A nurse is contributing to the plan of care for a client who has a chest tube connected
to a closed drainage system. Which ofIthe following actions should the nurse include in
, the Lplan Lof Lcare?
ANS: LMaintain Lthe Ldrainage Lsystem Lbelow Lthe Llevel Lof Lthe Lclient's Lchest.
7. A Lnurse Lin Lan Lacute Lmental Lhealth Lfacility Lis Lcaring Lfor La Lclient Lwho Lhas
Lborderline Lpersonality Ldisorder Land Lreports. L"I Lam Lgoing Lto Lkill Lmy Lgirlfriend Lwhen LI
Lget Lout Lof Lhere." LWhich LofIthe Lfollowing Lactions Lshould Lthe Lnurse Ltake?
ANS: LNotify Lthe Lclient's Lcare Lteam Lof Lthe Lthreats Lagainst Lthe LPartner
8. A Lnurse Lis Ladmitting La Lclient Lwho Lis Lat Lhigh Lrisk Lfor Lsuicide.Which LofIthe
Lfollowing Lactions Lis Lthe Lnurse's Lpriority?
ANS: LSearch Lthe Lclient's Lpersonal Lbelongings
9. A Lnurse Lis Lcaring Lfor La Lclient Lwho Lis L1 Lday Lpostoperative Land Lis Lunable Lto
Lambulate. LWhich Lof Lthe Lfollowing Lactions Lshould Lthe Lnurse Ltake Lto Lpromote Lthe
Lclient's Lvenous Lreturn?
ANS: LMaintain Lthe Lsequential Lcompression Ldevice.
10. A Lnurse Lin Lan Lacute Lcare Lunit Lis Lcollecting Ldata Lfrom La Lschool Lage LChild
Lwho Lhas Lcystic Lfibrosis. LWhich LofIthe Lfollowing Lfindings Lis Lthe Lpriority Lfor Lthe
Lnurse?
ANS: LReports Llack Lof Lappetite
11. A Lnurse Lworking Lin La Lprovider's Lfollowing Lreceives La Lphone Lcall Lfrom Lthe
Lparent Lof La Lschool Lage Lchild Lwho Lhas Lvaricella. LThe Lparent Lasked Lthe Lnurse
Lwhen Lthe Lchild Lcould Lreturn Lto Lschool. LWhich Lof Lthe Lfollowing Lresponses Lshould
Lthe Lnurse Lmake?
ANS: L"When Lthe Llesions Lhave Lscabbed Lover."
12. A Lnurse Lin La Lpediatric Lclinic Lis Lcollecting Lthe Ldata Lfrom La Lschool Lage Lchild
Lwhose Linjuries Lare Linconsistent Lwith Lthe Lparent's Lstated Lcause. LWhich LofIthe
Lfollowing Lactions Lshould Lthe Lnurse Ltake?
ANS: LReport Lthe Lsuspected Labuse Lto Lan Lappropriate Lagency.
13. A Lnurse Lis Lcollecting Ldata Lfrom La Lmiddle Ladult Lfemale Lclient Lwho Lis
Ltaking Lmelatonin.Which LofIthe Lfollowing Lresponses Lto Lthe Lmed Lshould Lthe
, Lnurse Lexpect? LANS: LImproved Lsleep
14. A Lnurse Lon La Lpediatric Lunit Lis Lcollecting Ldata Lfrom Lfour Lnewly Ladmitted Lclients.
LWhich LofIthe Lfollowing Lclients Lshould Lthe Lnurse Lidentify Las Lbeing Lat Lrisk Lfor
Lurinary Lretention?
ANS: LA Lschool Lage Lchild Lwho Lhas Lallergic Lrhinitis Land Lis Ltaking LDiphenhydramine.
15. A Lnurse Lis Lpreparing Lto Ladminister La Lpurified Lprotein Lderivative(PPD) Lto La Lclient
Lwho Lha Ls Lsuspected LTB. LWhich LofIthe Lfollowing Lactions Lshould Lthe Lnurse Lplan
Lto Ltake?
ANS: LEnsure Lthe Linjection Lproduces La Lwheal Lon Lthe Lskin
16. A Lclient Lwho Lis Ldiagnosed Lwith LParkinson's Ldisease Lverbalizes Lfrustration Ldue
Lto Lincreased Ldifficulty Lwith Lambulation. LWhich Lof Lthe Lfollowing Lresponses Lshould
Lthe Lnurse
take?
ANS: LPerform Lactive LROM Lwith Lyour Larms Land Llegs Ltwo Ltimes La Lday
17. A Lnurse Lis Lcollecting Ldata Lfrom La Lclient Lwho Lhas Lmultiple Lfractures
Lfollowing La Lmotor-vehicle Lcrash. LFor Lwhich Lof Lthe Lfollowing Lclient Lstatements
Lshould Lthe Lnurse Lrecommend La Lreferral Lto Lan Loccupational Ltherapist?
i Lam Lso Lfrustrated Li Lcannot Leven Lopen Lmy Lmilk Lcarton Lfor Lbreakfast
18. A Lnurse Lis Lcaring Lfor La Lclient Lwho Lis L4 Lhr Lpostoperative Lfollowing La Ltotal
Lthyroidectomy LWhich Lof Lthe Lfollowing Lmanifestations Lshould Lthe Lnurse Lreport Lto
Lthe Lprovider Las Lindicating Lpossible Lhypocalcemia?
ANS: LTingling Lof Lfingers
19. A Lnurse Lis Lcaring Lfor La Lclient Lwho Lhas La LPenrose Ldrain. LTo Lensure Lproper
Lplacement Land Lfunctioning Lof Lthe Ldrain, Lwhich Lof Lthe L following Lshould Lthe Lnurse
Lexpect Lto Lobserve?
, ANS: LThe Lsafety Lpin Lis Lpresent Lat Lthe Ldistal Lend Lof Lthe Ldrain.
20. A Lcommunity Lhealth Lnurse Lis Lhelping Lto Lreinforce Lteaching Labout Lhepatitis LA
Lwith La Lgroup Lof Lemployees Lat La Lchildcare Lfacility. LWhich Lof Lthe Lfollowing
Lcharacteristics Lshould Lthe Lnurse Lidentify Las Lan Lexternal Lfactor Lthat Lcan Limpede
Llearning Lfor Lthe Lparticipants?
ANS: LPoor Llighting Lin Lthe Llearning Lsetting
21. A Lnurse Lis Lobserving La Lnewly Llicensed Lnurse Lwho Lis Lproviding Ltracheostomy
Lcare Lfor La Lclient. LThe Lnurse Lidentifies Lproper Lperformance Lof Lthe Lprocedure Lwhen
Lthe Lnewly Llicensed Lnurse Lselects Lwhich Lof Lthe Lfollowing Lsolutions Lto Lclean Lthe
Linner Lcannula?
ANS: LHydrogen Lperoxide
22. A Lnurse Lis Lcaring Lfor La Lclient Lwho Lhas Lright Lsided Lheart Lfailure. LThe Lclient's
Lpartner Lexpresses Lconcern Lthat Lthe Lclient Lwill Ldie. LWhich LofIthe Lfollowing
Lresponses Lshould Lthe Lnurse Lmake?
ANS: L"It Lis Ldifficult Lto Lsee Lsomeone Lso Lsick. LWhat Lhave Lyou Lbeen Ltold Labout Lyour Lpartner's
Lprognosis?"
23. A Lnurse Lis Lreinforcing Ldischarge Linstructions Lwith Lthe Lparent Lof Lan Linfant Lwho Lhas