ANSWERS) 2025/26 VERIFIED 100%
CORRECT.
1 of 50
Term
The nurse is caring for a client who had lumbar spinal surgery 8 hours
ago. It would be a priority for the nurse to notify the
surgeon if
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B. Has had 125ml serosanguineous A. the patient was independently
fluid in the hemo-vac log rolling on the bed
, C. Has a moderate amount of
clear drainage on the surgical
dressing
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2 of 50
Term
A nurse working on a medical surgical unit has just received
a handoff report on the following clients. The nurse should
FIRST plan to assess the client who has:
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D. Initiate IV sodium and potassium for a client admitted with diarrhea and
dehydration who has a serum potassium level of 2.9.
Rationale – serum potassium of 2.9 is CRITICAL -this is a critical lab value and
should be addressed first!
D. A urinary output of 45 ml over the past two hours
Rationale – Normal urinary output per hour is 30 ml.hr. This question really has
nothing to do with “burn” and more know your normal values.
D. Acute pancreatitis and is reporting the development of pain on deep
inspiration
Rationale – “acute” if not caught early, will possible burst and patient will
become septic
, A – Heartbeat
Rationale – the only positive signs of pregnancy is heartbeat and lung sounds.
Remember there are positive signs of pregnancy and presumptive signs of
pregnancy.
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3 of 50
Definition
C. the client who has multiple compound fractures and is reporting
chest pain Rationale – patient is reporting chest pain
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The charge nurse in the ED is reviewing the care provided for recently
admitted clients. which of the following reflects implementation of an
accep ted standard of care?
The nurse is assessing clients at the scene of a mass casualty disaster
and is prioritizing care based on the disaster triage tag system. Which of
the following clients should be transported to the health care facility
FIRST?
The nurse working in the psychiatric inpatient unit is caring for a client who has
bi-polar disorder and is in the manic phase. The client states to the nurse, “I
am bored.” Which of the following activities is appropriate for the nurse to
suggest to the client?
The nurse working on a medical surgical unit is delegating tasks to unlicensed
personnel. Which of the following delegated task would REQUIRE FOLLOW UP
, by the charge nurse?
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4 of 50
Term
The nurse has instructed a client who must ambulate with a cane.
Which of the following client statements indicates a correct
understanding of the teaching?
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A – I will place the cane on the side of the unaffected limb and walk with
the weaker leg first.
Rationale – the cane goes on the side where the leg is strongest.
A – You should report the development of tendon pain while taking this
medication, since tendon rupture is a potential complication
Rationale – Know u DRUGS!
A. I will clean the hearing aids with alcohol wipes - This is a false statement!!
Rationale – you are looking for the incorrect statement in the answer – you
clean your hearing aids with plain soap and water – NOT alcohol wipes
A - I will perform my self breast examination 7 days after my period ends - you
do it 7 days post as the hormones have decreased and any natural lumps will
disappear, and breasts will not be as tender and sore
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