UPDATE!!!2025/2026|GUARANTEED
S. A nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site.
Based on these findings, the nurse implements which action?
a. Discontinues the IV
b. Applies a warm compress
c. Checks for a blood return
d. Measures the area of infiltration - ANSWER a
(This question requires that you focus on the data identified in the question and determine
that the client is experiencing an infiltration. Next you need to consider the harmful effects
of infiltration and determine the action to implement. Because infiltration can be damaging
to the surrounding tissue, the most appropriate action is to discontinue the IV to prevent
any further damage.)
S. A nurse has received the client assignment for the day. Which client should the nurse
assess first?
a. The client who has a nasogastric tube attached to intermittent suction
b. The client who needs to receive subcutaneous insulin before breakfast
1
,c. The client who is 2 days postoperative and is complaining of incisional pain
d. The client who has a blood glucose level of 50 mg/dL and complaints of blurred vision -
ANSWER d
(This question requires you to establish priorities by comparing the needs of each client and
deciding which need is urgent. The client described in option 4 has a blood glucose level and
symptoms reflective of hypoglycemia. This client should be assessed first so that treatment
can be implemented. Although the clients in options 1, 2, and 3 have needs that require
assessment, they are not a priority and can wait until the client in option 4 is stabilized.)
S. A nurse prepares to care for a client on contact precautions who has a hospital-acquired
infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an
abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical
ventilator, which requires frequent suctioning. The nurse assembles which of the following
necessary protective items before entering the client's room?
a. Gloves and a gown
b. Gloves, mask, and goggles
c. Gloves, mask, gown, and goggles
d. Gloves, gown, and shoe protectors - ANSWER c
(This question addresses content related to protecting oneself from contracting an infection
and requires that you consider the methods of possible transmission of infection, based on
the client's condition. Because splashes of infective material can occur during the wound
irrigation or suctioning of the tracheostomy, option 3 is correct.)
2
,S. The nurse is choosing age-appropriate toys for a toddler. Which of the following would be
the best toy?
a. Puzzle
b. Toy soldiers
c. Large stacking blocks
d. A card game with large pictures - ANSWER c
(Toddlers like to master activities independently, such as stacking blocks. Because toddlers
do not have the developmental ability to determine what could be harmful, toys that are
safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the
mouth and may be harmful for a toddler. A card game with large pictures may require
cooperative play, which is more appropriate for a school-age child.)
S. A client with coronary artery disease has selected guided imagery to help cope with
psychological stress. Which of the following statements indicates the client's understanding
of this stress reduction measure?
a. "This will work for me only if I am alone in a quiet area."
b. "This will help only if I play music at the same time."
c. "I need to do this only when I lie down in case I fall asleep."
d. "The best thing about this is that I can use it anywhere, anytime." - ANSWER d
3
, (Guided imagery involves the client's creation of an image in the mind, concentrating on the
image, and gradually becoming less aware of the offending stimulus. It can be done anytime
and anywhere; some clients may use other relaxation techniques or play music with it.)
S. A client with Parkinson's disease develops akinesia while ambulating, increasing the risk
for falls. Which suggestion should the nurse provide to the client to alleviate this problem?
a. Use a wheelchair to move around.
b. Stand erect and use a cane to ambulate.
c. Keep the feet close together while ambulating and use a walker.
d. Consciously think about walking over imaginary lines on the floor. - ANSWER d
(This question addresses client mobility and promoting assistance in an activity of daily living
to maintain safety. Clients with Parkinson's disease can develop bradykinesia (slow
movement) or akinesia (freezing or no movement). Having these clients imagine lines on the
floor to step over can keep them moving forward while remaining safe.)
S. The nurse monitors a client receiving digoxin (Lanoxin) for which early manifestation of
digoxin toxicity?
a. Anorexia
b. Facial pain
c. Photophobia
d. Yellow color perception - ANSWER a
4
S. A nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site.
Based on these findings, the nurse implements which action?
a. Discontinues the IV
b. Applies a warm compress
c. Checks for a blood return
d. Measures the area of infiltration - ANSWER a
(This question requires that you focus on the data identified in the question and determine
that the client is experiencing an infiltration. Next you need to consider the harmful effects
of infiltration and determine the action to implement. Because infiltration can be damaging
to the surrounding tissue, the most appropriate action is to discontinue the IV to prevent
any further damage.)
S. A nurse has received the client assignment for the day. Which client should the nurse
assess first?
a. The client who has a nasogastric tube attached to intermittent suction
b. The client who needs to receive subcutaneous insulin before breakfast
1
,c. The client who is 2 days postoperative and is complaining of incisional pain
d. The client who has a blood glucose level of 50 mg/dL and complaints of blurred vision -
ANSWER d
(This question requires you to establish priorities by comparing the needs of each client and
deciding which need is urgent. The client described in option 4 has a blood glucose level and
symptoms reflective of hypoglycemia. This client should be assessed first so that treatment
can be implemented. Although the clients in options 1, 2, and 3 have needs that require
assessment, they are not a priority and can wait until the client in option 4 is stabilized.)
S. A nurse prepares to care for a client on contact precautions who has a hospital-acquired
infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an
abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical
ventilator, which requires frequent suctioning. The nurse assembles which of the following
necessary protective items before entering the client's room?
a. Gloves and a gown
b. Gloves, mask, and goggles
c. Gloves, mask, gown, and goggles
d. Gloves, gown, and shoe protectors - ANSWER c
(This question addresses content related to protecting oneself from contracting an infection
and requires that you consider the methods of possible transmission of infection, based on
the client's condition. Because splashes of infective material can occur during the wound
irrigation or suctioning of the tracheostomy, option 3 is correct.)
2
,S. The nurse is choosing age-appropriate toys for a toddler. Which of the following would be
the best toy?
a. Puzzle
b. Toy soldiers
c. Large stacking blocks
d. A card game with large pictures - ANSWER c
(Toddlers like to master activities independently, such as stacking blocks. Because toddlers
do not have the developmental ability to determine what could be harmful, toys that are
safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the
mouth and may be harmful for a toddler. A card game with large pictures may require
cooperative play, which is more appropriate for a school-age child.)
S. A client with coronary artery disease has selected guided imagery to help cope with
psychological stress. Which of the following statements indicates the client's understanding
of this stress reduction measure?
a. "This will work for me only if I am alone in a quiet area."
b. "This will help only if I play music at the same time."
c. "I need to do this only when I lie down in case I fall asleep."
d. "The best thing about this is that I can use it anywhere, anytime." - ANSWER d
3
, (Guided imagery involves the client's creation of an image in the mind, concentrating on the
image, and gradually becoming less aware of the offending stimulus. It can be done anytime
and anywhere; some clients may use other relaxation techniques or play music with it.)
S. A client with Parkinson's disease develops akinesia while ambulating, increasing the risk
for falls. Which suggestion should the nurse provide to the client to alleviate this problem?
a. Use a wheelchair to move around.
b. Stand erect and use a cane to ambulate.
c. Keep the feet close together while ambulating and use a walker.
d. Consciously think about walking over imaginary lines on the floor. - ANSWER d
(This question addresses client mobility and promoting assistance in an activity of daily living
to maintain safety. Clients with Parkinson's disease can develop bradykinesia (slow
movement) or akinesia (freezing or no movement). Having these clients imagine lines on the
floor to step over can keep them moving forward while remaining safe.)
S. The nurse monitors a client receiving digoxin (Lanoxin) for which early manifestation of
digoxin toxicity?
a. Anorexia
b. Facial pain
c. Photophobia
d. Yellow color perception - ANSWER a
4
