RATIONALE] LATEST VERSION [QUESTIONS AND
ANSWERS] DETAILED AND VERIFIED FOR
GUARANTEED PASS- LATEST UPDATE 2025 GRADED A
(BRAND NEW!!)
1. A home health nurse is conducting an initial home visit for a client who has terminal
breast cancer. The client has two school-age children and a limited support system.
Which of the following is the priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding child care options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis - CORRECT ANSWER
✔✔✔✔✔ Inform the client of available community resources
2. A nurse in an emergency department is assessing a client who has a nasal fracture.
Which of the following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry - CORRECT ANSWER ✔✔✔✔✔ Clear fluid drainage from
the nares
3. A nurse in an urgent care clinic is collecting admission history from a client who is at
16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that
which of the following clinical findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria - CORRECT ANSWER ✔✔✔✔✔ Profuse milky white discharge
4. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed
nurse. Which of the following statements indicates the newly licensed nurse
understands the purpose of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug - CORRECT ANSWER
✔✔✔✔✔ This technique decreases the risk of subcutaneous infiltration
,10. A nurse is caring for a full-term newborn immediately following birth. Which of the
following actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn's eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn - CORRECT ANSWER ✔✔✔✔✔ Dry the newborn
11. A nurse is planning to provide community education about viral hepatitis. Which of
the following should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
D. Clients who have a history of viral hepatitis are unable to donate blood - CORRECT
ANSWER ✔✔✔✔✔ Clients who have a history of viral hepatitis are unable to donate
blood
12. A nurse in a residential mental health facility is planning care for a new client who
has obsessive compulsive disorder. Which of the following is appropriate for the nurse
to include in the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts - CORRECT ANSWER
✔✔✔✔✔ Work with the client to create a flexible daily schedule
13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify
that the client's BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity - CORRECT ANSWER ✔✔✔✔✔ Malnutrition
14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The
last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the
end of the last contraction, the nurse observes a large gush of fluid coming out of the
client's perineal area. Which of the following is a priority action by the nurse?
A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid - CORRECT ANSWER ✔✔✔✔✔ Check the FHR
15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of
the following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
,D. Allow the client to choose meal times - CORRECT ANSWER ✔✔✔✔✔ Monitor the
client for 1 hr after meals
16. A nurse is performing a skin assessment on a client who has risk factors for
development of skin cancer. The nurse should understand that a suspicious lesion is
A. Asymmetric, with variegated coloring
B. Scaly and red
C. Brown, with a wart-like texture
D. Firm and rubbery - CORRECT ANSWER ✔✔✔✔✔ Asymmetric, with variegated
coloring
17. A nurse is assessing a client's internal eye structures with an ophthalmoscope.
Which of the following actions should the nurse take?
A. Position the examination light toward the client's face
B. Stand on the right side of the client when examining the left eye
C. Dim the lights in the room prior to the examination
D. Place the ophthalmoscope directly against the client's forehead - CORRECT
ANSWER ✔✔✔✔✔ Dim the lights in the room prior to the examination
18. A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the
following actions should the nurse identify as an indication that the newly licensed nurse
understands wound irrigation?
A. Cleanses the wound with povidone-iodine with cotton balls
B. Administers PO analgesia 20 min prior to irrigation
C. Warms the irrigation solution in the microwave oven prior to application
D. Irrigates the wound from the top to the bottom - CORRECT ANSWER ✔✔✔✔✔
Administers PO analgesia 20 minutes prior to irrigation
19. A nurse is planning care for a child who has increased intracranial pressure with a
decrease in level of consciousness. Which of the following interventions should the
nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs - CORRECT ANSWER ✔✔✔✔✔ Maintain
the head at a midline position
20. A nurse notices smoke coming from a client's room and discovers a fire in the
wastebasket. After moving the client to safety, which of the followings is the priority
action?
A. Notify the facility operator
B. Close the fire doors on the unit
C. Turn off oxygen sources
D. Put out the fire with the appropriate extinguisher - CORRECT ANSWER ✔✔✔✔✔
Close the fire door on the unit
, 21. A nurse is talking with an adult child of a client who was involuntarily admitted to an
inpatient mental health facility. Which of the following statements should the nurse
make?
A. The provider will notify your patient's employer about admission to the facility
B. Your parent will have to take the medication that the doctor prescribes
C. Your parent might have electroconvulsive therapy without providing consent
D. The provider can prescribe restraints if your parent tries to harm others - CORRECT
ANSWER ✔✔✔✔✔ The provider can prescribe restraints if your parent tries to harm
others
22. A nurse is assessing a client who has delirium due to a febrile illness. Which of the
following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia - CORRECT ANSWER ✔✔✔✔✔ Hallucinations
23. A nurse is assessing a client who is receiving enteral feedings via a gastrostomy
tube. The nurse should identify that which of the following findings indicates fluid
overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses - CORRECT ANSWER ✔✔✔✔✔ Bounding pulses
24. A nurse is caring for a client following an open colectomy. Which of the following
findings places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain - CORRECT ANSWER ✔✔✔✔✔ Hyperemesis
25. A nurse is assessing a client who has a complete heart block and is receiving
transcutaneous pacing. Which of the following findings indicates to the nurse that the
treatment is effective?
A. Heart rate greater than 60/min
B. Pedal pulses 2+
C. Pacer spikes after the QRS complex
D. Distended jugular veins - CORRECT ANSWER ✔✔✔✔✔ Heart rate greater than
60/min
26. A nurse is caring for a client who is taking levothyroxine. Which of the following
findings should indicate to the nurse that the medication is effective?
A. Decreased blood pressure
B. Weight loss
C. Decreased inflammation