RATIONALE] LATEST VERSION [QUESTIONS AND
ANSWERS] DETAILED AND VERIFIED FOR
GUARANTEED PASS- LATEST UPDATE 2025 GRADED A
(BRAND NEW!!)
A nurse is reinforcing discharge teaching with a client who is postoperative following
laser surgery for open-angle glaucoma. Which of the following statements by the client
indicates an understanding of the instructions? - CORRECT ANSWER ✔✔✔✔✔ I will
take a stool softener to prevent constipation
A nurse is caring for a client who had a stroke and is having difficulty swallowing. The
nurse should recommend a referral to which of the following members of the
interprofessional team? - CORRECT ANSWER ✔✔✔✔✔ Speech therapist
A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an
episiotomy. Which of the following instructions should the nurse include? - CORRECT
ANSWER ✔✔✔✔✔ Change the perineal pad with each void
A nurse is collecting data from a child who has acute Glomerulonephritis. Which of the
following findings should the nurse expect? - CORRECT ANSWER ✔✔✔✔✔
Periorbital edema
A nurse is preparing to administer a liquid medication to a 6-month-old infant who is
crying. Which of the following actions should the nurse take to reduce the risk of
aspiration? - CORRECT ANSWER ✔✔✔✔✔ Administer using a needless syringe in
the buccal cavity
A nurse is reinforcing teaching with a client who has peptic ulcer disease. Which of the
following statements by the client indicates an understanding of the teaching? -
CORRECT ANSWER ✔✔✔✔✔ I will plan to have my meals at regular intervals
A nurse in long-term care facility has received change-of-shift report about four clients.
Which of the following clients should the nurse attend to first? - CORRECT ANSWER
✔✔✔✔✔ A client who has COPD and dementia and was agitated during the night shift
A nurse is collecting data from a client who has substance use disorder and reports
recently taking opioids. Which of the following findings should the nurse identify as a
manifestation of opioid intoxication? - CORRECT ANSWER ✔✔✔✔✔ Pinpoint pupils
,A nurse in a urgent care clinic is collecting data from a client who reports having
diarrhea for the past 3 days. Which of the following findings indicates hypokalemia? -
CORRECT ANSWER ✔✔✔✔✔ Muscle weakness
A nurse is contributing to the discharge plans for four clients. The nurse should identify
that which of the following clients requires an interdisciplinary care conference? -
CORRECT ANSWER ✔✔✔✔✔ A client who has hemiparesis and lives alone
A nurse is reinforcing teaching with an adolescent who has a new prescription for
cefazolin. For which of the following findings should the nurse instruct the adolescent to
monitor and report to the provider? - CORRECT ANSWER ✔✔✔✔✔ Depression
A nurse is reinforcing teaching with a group of expectant parents regarding the proper
use of a car seat. Which of the following statements by a parent indicates an
understanding of the teaching? - CORRECT ANSWER ✔✔✔✔✔ I can place a rolled
towel on each side of my newborns head until he can hold his head up
A nurse is caring for a school-age child who has epistaxis. Which of them following
actions should the nurse take? - CORRECT ANSWER ✔✔✔✔✔ Apply pressure at the
bridge of the child's nose
A nurse is caring for four clients. Which of the following clients statements should the
nurse attend to first? - CORRECT ANSWER ✔✔✔✔✔ My heartburn pain is going into
my jaw now
A nurse in a providers office is talking on the phone with the parent of a school-age child
who has varicella. - CORRECT ANSWER ✔✔✔✔✔ All vesicles have crusted over
A nurse is collecting data from a client who hgb is 8.8 mg/dL. Which of the following
statements should the nurse expect? - CORRECT ANSWER ✔✔✔✔✔ I feel tired all
the time
A nurse is administering a cleansing enema to a client who reports mild cramping during
instillation of the solution. Which of the following actions should the nurse take? -
CORRECT ANSWER ✔✔✔✔✔ Slow the rate of instillation
A nurse receives report on four clients. The nurse should first collect data about the
client who has which of the following? - CORRECT ANSWER ✔✔✔✔✔ A decreased
level of consciousness and vomiting
A nurse is setting up a sterile field prior to performing a dressing change. Which of the
following actions should the nurse take? - CORRECT ANSWER ✔✔✔✔✔ Open the
outermost flap of the wrapper toward the body
,A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which
of the following actions should the nurse take? - CORRECT ANSWER ✔✔✔✔✔
Frequently remind the client of the expectations for her behavior
A nurse is caring for a client who has viral pneumonia. Which of the following actions
should the nurse take? - CORRECT ANSWER ✔✔✔✔✔ Administer Azithromycin
A nurse who orienting to a medical-surgical unit is having difficulty finishing client care
tasks during his shift. Which of the following suggestions should the nurse's preceptor
make to help the nurse with time management? - CORRECT ANSWER ✔✔✔✔✔ Try
to complete a task before moving on to the next.
A nurse is caring for an older adult client who is postoperative following a total hip
arthroplasty. The nurse is preparing to change the client's dressing. Which of the
following actions should the nurse take to demonstrate sensitivity to age-related
changes? - CORRECT ANSWER ✔✔✔✔✔ Use paper tape for securing the new
dressing.
A nurse working in an inpatient mental health facility is assisting with the plan of care for
a client who has anorexia nervosa. Which of the following should the nurse recommend
to include in the plan of care? - CORRECT ANSWER ✔✔✔✔✔ Maintain continuity of
staff members.
A nurse is assisting with an admission interview for a client who has schizophrenia. He
tells the nurse that he is receiving special audible messages from the Central
Intelligence Agency that no one else is able to hear. The nurse should identify that the
client is having which of the following alterations in perception? - CORRECT ANSWER
✔✔✔✔✔ Hallucination
A nurse is reinforcing teaching with a postpartum client about bathing her newborn.
Which of the following statements should the nurse include? - CORRECT ANSWER
✔✔✔✔✔ "Wash your newborn's head under a stream of running water."
A nurse is caring for a client who has heart failure and reports difficulty limiting sodium
in his diet. Which of the following recommendations should the nurse provide? -
CORRECT ANSWER ✔✔✔✔✔ Replace bottled salad dressing with homemade
vinegar and oil dressing.
A nurse is reinforcing teaching about nonpharmacological pain relief with a client who is
6 hr postpartum following a vaginal delivery. The client has an episiotomy and swelling
of the labia. Which of the following instructions should the nurse include? - CORRECT
ANSWER ✔✔✔✔✔ Sit on soft pillows throughout the day.
A nurse is caring for a client who has a new colostomy. He voices a reluctance about
resuming sexual relations. Which of the following is an appropriate response by the
, nurse? - CORRECT ANSWER ✔✔✔✔✔ "I'm available if you'd like to talk about your
concerns."
A nurse is reinforcing discharge teaching about transmission precautions with a client
who has hepatitis C. Which of the following information should the nurse include? -
CORRECT ANSWER ✔✔✔✔✔ Avoid sharing razors with other family members.
A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus.
Which of the following client statements indicates to the nurse a need for further
teaching? - CORRECT ANSWER ✔✔✔✔✔ "I will be sure to wear cotton socks."
A nurse is contributing to the plan of care for a client who has bulimia nervosa. Which of
the following interventions should the nurse recommend? - CORRECT ANSWER
✔✔✔✔✔ Observe the client for 1 hr after meals.
A nurse is assisting with the discharge planning for a client following a myocardial
infarction. Which of the following is an appropriate referral for this client? - CORRECT
ANSWER ✔✔✔✔✔ Respiratory therapist for breathing exercises
A nurse is contributing to the discharge plan of an older adult client who had a total hip
arthroplasty. The client is unable to ambulate independently and lives alone. Which of
the following care settings should the nurse recommend for this client? - CORRECT
ANSWER ✔✔✔✔✔ Skilled nursing facility
A nurse is reinforcing teaching with the parents of a preschool-age child who has a new
diagnosis of celiac disease. Which of the following foods should the nurse recommend?
- CORRECT ANSWER ✔✔✔✔✔ Corn tortillas with black beans
A nurse is assisting with the admission of a client who has mononucleosis. Which of the
following isolation precautions should the nurse initiate? - CORRECT ANSWER
✔✔✔✔✔ Droplet
A nurse is speaking to a client who called the provider's office to report chest pain and
requests clarification on how to take his sublingual nitroglycerin tablets. Which of the
following instructions should the nurse give the client? - CORRECT ANSWER ✔✔✔✔✔
Wait 5 min between doses.
A nurse is caring for a client and begins to suspect he is experiencing transference.
Which of the following client statements should the nurse identify as an indicator of
transference? - CORRECT ANSWER ✔✔✔✔✔ "I feel really close to you because you
remind me of my ex-boyfriend."
A nurse is caring for a client who has been placed in restraints. Which of the following is
appropriate? - CORRECT ANSWER ✔✔✔✔✔ Monitor the client's skin integrity on a
regular schedule.