AND CORRECT ANSWERS 2025-2026 UPDATE||ALREADY
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The nurse is completing the admission assessment of a 3-year old who
is admitted with bacterial meningitis and hydrocephalus. Which
assessment finding is evidence that the child is experiencing increased
intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope - Answer-B. Sluggish and
unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing
abdominal pain and an elevated serum amylase. Which additional
information is the client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. - Answer-A.
Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being
discharged from the hospital. Which information is most important for
the nurse to provide the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family - Answer-A.
Instructions about how much fluid the child should drink daily
pg. 1
,To auscultate for a carotid bruit, the nurse places the stethoscope at
what location. (Select the location on the image with a red dot). -
Answer-I placed the red dot on the base of the neck on the right side
After receiving report on an inpatient acute care unit, which client
should the nurse assess first?
A. The client with an obstruction of the large intestine who is
experiencing abdominal distention
B. The client who had surgery yesterday and is experiencing a
paralytic ileus with absent bowel sounds
C. The client with a small bowel obstruction who has a nasogastric
tube that is draining greenish fluid
D. The client with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity - Answer-D. The client with a bowel
obstruction due to a volvulus who is experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations
after vaping at a party. The client is anxious, fearful, and
hyperventilating. The nurse anticipates the client developing which
acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis - Answer-D. Respiratory alkalosis
A client with dyspnea is being admitted to the medical unit. To best
prepare for the client's arrival, the nurse should ensure that the client's
bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers - Answer-Fowlers
pg. 2
,The nurse is taking the blood pressure measurement of a client with
Parkinson's disease. Which information in the client's admission
assessment is relevant to the nurse's plan for taking the blood pressure
reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling - Answer-A. Frequent syncope
While caring for a client's postoperative dressing, the nurse observes
purulent drainage at the wound. Before reporting this finding to the
healthcare provider, the nurse should review which of the client's
laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level - Answer-B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following
successful resuscitation from a near-drowning incident. While
providing care to the child, the nurse begins talking with his
preadolescent brother who rescued the child from the swimming pool
and initiated resuscitation. The nurse notices the older boy becomes
withdrawn when asked about what happened. Which action should the
nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions - Answer-B. Ask
the older brother how he felt during the incident
pg. 3
, A male client with cirrhosis has jaundice and pruritus. He tells the
nurse that he has been soaking in hot baths at night with no relief of
his discomfort. Which action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion
after soaking
B. Obtain a PRN prescription for an analgesic that the client can use
for symptom relief
C. Suggest that the client take brief showers and apply oil-based
lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot
be relieved - Answer-A. Encourage the client to use cooler water and
apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD),
hypertension (HTN), and heart failure (HF) arrives in the Emergency
Department (ED) in respiratory distress. The healthcare provider
prescribes furosemide IV. Which therapeutic response to furosemide
should the nurse expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload - Answer-B. Reduced preload
Which intervention should the nurse include in the plan of care for a
child with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light - Answer-B.
Minimize the amount of stimuli in the room
pg. 4