Answers| LATEST,2025/2026 With Correct Answers & Z Z Z
Rationale Z
1 A nurse is caring for a client who has bipolar disorder and is experiencing acute
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Zmania. The nurse obtained a verbal prescription for restraints. Which of the
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Zfollowing should the actions the nurse take?Z Z Z Z Z Z
Document the client's condition every 15 minutes
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2 A nursing planning care for a school-age child who is 4 hr postoperative
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Zfollowing perforated appendicitis. Which of the following actions should the
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Znurse include in the plan of care?
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Administer analgesics on a scheduled basis for the first 24 hr
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3 A nurse is receiving a change-of-shift report for a group of clients. Which of the
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Zfollowing clients should the nurse plan to assess first?
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A client who has a hip fracture and a new onset of tachypnea
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4 A nurse is preparing to apply a transdermal nicotine patch for a client. Which of
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Zthe following actions should the nurse take?
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Wear gloves to apply the patch to the client's skin
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5 A nurse has just received a change-of-shift report for four clients. Which of the
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Zfollowing clients should the nurse assess first?
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A client who was just given a glass of orange juice for a low blood glucose level
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6 A nurse is caring for a client who is receiving intermittent enteral tube feedings.
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ZWhich of the following places the client at risk for aspiration?
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A history of gastroesophageal reflux disease
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7 A nurse is reviewing the laboratory results for a client who has Cushing's
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Zdisease. The nurse should expect the client to have an increase in which of
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Zthe following laboratory values?
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Serum glucose level- increased
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, 8 A nurse is caring for a client who has severe preeclampsia and is receiving
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magnesium sulfate intravenously. The nurse discontinues the magnesium
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sulfate after the client displaces toxicity. Which of the following actions should
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the nurse take?
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Administer calcium gluconate IV Z Z Z
Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an
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injectable form of
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calcium gluconate available when administering magnesium sulfate by IV.
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9 A charge nurse is teaching new staff members about factors that increase a
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client's risk to become violent. Which of the following risk factors should the
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nurse include as the best predictor of future violence?
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Previous violent behavior Z Z
Risk factors also include: past history of aggression, poor impulse control, and violence.
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Comorbidity that leads to acts of violence (psychotic delusions, command
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hallucinations, violent angry reactions with cognitive disorders).
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10 A nurse is preparing to perform a sterile dressing change. Which of the
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following actions should the nurse take when setting up the sterile field?
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Place the cap from the solution sterile side up on clean surface
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11 A nurse is providing teaching to an older adult client about methods to
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promote nighttime sleep. Which of the following instructions should the
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nurse include?
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Eat a light snack before bedtime
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12 A home health nurse is preparing for an initial visit with an older adult client
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who lives alone. Which of the following actions should the nurse take first?
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Identify environmental hazards in the home
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, 13 A nurse is assessing the remote memory of an older adult client who has mild
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Zdementia. Which of the following questions should the nurse ask the client?
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Z"What high school did you graduate from"
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14 A nurse is providing teaching to an adolescent who has type 1 diabetes
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mellitus. Which of the following goals should the nurse include in the
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teaching? HbA1c level less than 7%
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15 A nurse is caring for a client who is 1 hr postoperative following rhinoplasty.
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Z Which manifestations require immediate action by the nurse?
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Increase in frequency of swallowing
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16 A nurse is planning care for a preschool-age child who is in the acute phase of
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Kawasaki disease. Which of the following interventions should the nurse include
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in the plan of care?
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Monitor the child's cardiac status
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17 A nurse is planning an educational program for high school students about
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Zcigarette smoking. Which of the following potential consequences of smoking is
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Zmost likely to discourage adolescents from using tobacco?
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Use of tobacco decreases the level of athletic ability
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18 A nurse is assessing a client who is prescribed spironolactone. Which of the
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Zfollowing laboratory values should the nurse monitor for this client?
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Serum potassium- diuretic that retains potassium= hyperkalemia risk
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19 A nurse has agreed to serve as an interpreter for an older adult client who is
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Zassigned to another nurse. Which of the following statements by the nurse
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Zindicates an understanding of this role?
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