Exam Questions and Correct Answers (3
Versions) For Guaranteed Pass
Question 1: A school nurse is assessing a child who has been stung by a bee. The child's hand is
swelling and the nurse notes that the child is allergic to insect stings. Which of the following
findings should the nurse expect if the child develops anaphylaxis? (Select all that apply)
A) Bradycardia
B) Nausea
C) Hypertension
D) Urticaria
E) Stridor
Correct Answer: B, D, E
Explanation: Anaphylaxis is a severe allergic reaction that can include nausea (due to
gastrointestinal involvement), urticaria (hives from histamine release), and stridor (airway
obstruction from swelling). Bradycardia and hypertension are not typical; instead, tachycardia
and hypotension are more common due to vasodilation and shock.
Question 2: A nurse is caring for a client who is unconscious. Which of the following actions
should the nurse take when providing oral care for the client?
A) Test for the presence of the client's gag reflex
B) Place the client in the supine position
C) Use a firm toothbrush for tooth and gum care
D) Use 2 gauze-wrapped fingers to hold the mouth open
Correct Answer: A
Explanation: Testing the gag reflex is essential to prevent aspiration in an unconscious client.
Supine position increases aspiration risk, a firm toothbrush may cause injury, and using fingers
to hold the mouth open risks biting or injury.
Question 3: A nurse is planning care for a client who has acute myelogenous leukemia and a
platelet count of 48,000/mm³. Which of the following interventions should the nurse include?
A) Avoid IM injections
,B) Assess the client for ecchymosis once per shift
C) Do not allow the client to have visitors
D) Encourage daily flossing between teeth
Correct Answer: A
Explanation: Low platelet counts increase bleeding risk, so avoiding IM injections prevents
hematoma formation. Assessing for ecchymosis should be more frequent, visitors are allowed
with precautions, and flossing can cause gum bleeding.
Question 4: A nurse is preparing to assess the function of the client's trigeminal nerve (cranial
nerve V). Which of the following items should the nurse gather for the test?
A) Sugar
B) Coffee
C) Cotton wisps
D) Snellen chart
Correct Answer: C
Explanation: The trigeminal nerve is tested for sensation using light touch with cotton wisps.
Sugar and coffee test taste (cranial nerves VII/IX), and the Snellen chart tests vision (cranial
nerve II).
Question 5: A nurse is caring for a client with alcohol use disorder who has undergone
detoxification. Which of the following medications should the nurse expect the provider to
prescribe to assist the client with maintaining sobriety?
A) Varenicline
B) Clonidine
C) Buprenorphine
D) Disulfiram
Correct Answer: D
Explanation: Disulfiram causes adverse reactions with alcohol, deterring consumption.
Varenicline is for smoking cessation, clonidine for hypertension/withdrawal, and buprenorphine
for opioid dependence.
Question 6: A newly admitted client who has major depressive disorder states to the nurse, "I'm a
failure, I can't even cope with the little things anymore." Which of the following responses
should the nurse provide?
A) "What happened in your life to make you feel like such a failure?"
,B) "It sounds as if you are feeling pretty overwhelmed right now"
C) "Do you feel like you don't deserve to feel good about yourself?"
D) "I know you feel like that now, but you'll feel differently when you get better"
Correct Answer: C
Explanation: This response explores self-esteem issues common in depression. Option A is
judgmental, B restates feelings (therapeutic but not best), and D minimizes the client's current
emotions.
Question 7: A nurse is caring for a middle-aged adult client. The nurse should identify which of
the following statements as an indication that the client has completed Erikson's developmental
task for her age group?
A) "I am comfortable with my decision to choose a lifelong partner."
B) "I think I have done a good job with my children since they are all independent now."
C) "As I look back over my life, I can see that I have achieved most of the goals I set for
myself."
D) "I love my work so much that it's difficult to think about retirement."
Correct Answer: B
Explanation: Middle adulthood (Erikson's generativity vs. stagnation) involves contributing to
the next generation, like raising independent children. A is intimacy (young adulthood), C is ego
integrity (older adulthood), and D relates to career but not generativity.
Question 8: A nurse is conducting an admission interview with a client. Which of the following
pieces of assessment information should the nurse collect during the introductory phase of the
interview?
A) Client's level of comfort and ability to participate in the interview
B) Previous illnesses and surgeries
C) Events surrounding the client's recent illness
D) Sociocultural history
Correct Answer: A
Explanation: The introductory phase establishes rapport and assesses readiness/comfort. Other
options are for the working phase.
Question 9: A nurse is planning to assess the abdomen of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use first?
A) Inspection
, B) Auscultation
C) Percussion
D) Palpation
Correct Answer: A
Explanation: Abdominal assessment order is inspection, auscultation, percussion, palpation to
avoid altering bowel sounds. Inspection first observes for distention or asymmetry.
Question 10: A nurse is performing a comprehensive physical assessment of a client. The nurse
should use inspection to assess which of the following?
A) Liver size
B) Pedal edema
C) Skin texture
D) Gait
Correct Answer: D
Explanation: Gait is assessed visually via inspection. Liver size requires percussion/palpation,
pedal edema and skin texture require palpation.
Question 11: A nurse is caring for a client who is immobile. The nurse should recognize that
immobility places the client at risk of which of the following health alterations?
A) Increased intestinal motility
B) Respiratory alkalosis
C) Decreased cardiac output
D) Hypocalcemia
Correct Answer: C
Explanation: Immobility reduces venous return, leading to decreased cardiac output. Motility
decreases (constipation risk), acidosis (not alkalosis) from poor ventilation, and hypercalcemia
from bone resorption.
Question 12: A nurse is preparing to perform mouth care for an unresponsive client. Which of
the following actions should the nurse plan to take?
A) Place the client supine
B) Keep both side rails up
C) Raise the level of the bed
D) Inspect the client's mouth using a finger sweep