All 2023/2024 Actual Exam versions Combined and Reviewed.
500+ Questions and Verified Answers.
t
Question 1 of 180
A nurse is caring for a client who refuses a blood transfusion. Which of the following actions
ne
should the nurse take?
◯ Notify risk management about the client’s refusal.
◯ Document the client’s refusal in the medical record.
◯ Inform the client that the transfusion is mandatory.
sh
◯ Suggest that the client explore alternative therapies.
Correct Answer:
Document the client’s refusal in the medical record.
Explanation:
The nurse should document the client's refusal to ensure proper documentation of the client’s
la
decision for legal and ethical reasons.
Sp
Question 2 of 180
A nurse is caring for a client at a clinic.
Admission Assessment
1 week ago: Client reports that manifestations of hopelessness and disinterest are lessened, but
present. Sleep disturbance continues. Provider increased paroxetine to 30 mg daily. Return to
clinic in 1 week.
2 weeks ago: Client with a history of generalized anxiety disorder and major depressive disorder.
Client presents with increased hopelessness, disinterest, and a change in sleep and appetite over
, several months. Client is currently taking fluoxetine 20 mg daily for the past year. Fluoxetine
discontinued and paroxetine 10 mg daily started. Return to clinic in 1 week.
Complete the following sentence by using the lists of options.
The client is at risk for developing Select ____________ due to ____________.
t
Correct Answer:
The client is at risk for developing Serotonin syndrome due to increasing the dose of paroxetine.
ne
Explanation:
Increasing the dosage of serotonin-enhancing medications like paroxetine can lead to serotonin
syndrome, which is a potential complication.
sh
Question 3 of 180
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of pulmonary congestion?
◯ Frothy, pink sputum
la
◯ Weight gain
◯ Bradypnea
◯ Jugular vein distention
Sp
Correct Answer:
Frothy, pink sputum
Explanation:
Frothy, pink sputum is a classic sign of pulmonary edema, which is associated with left-sided
heart failure and pulmonary congestion.
Question 4 of 180
A nurse on a medical-surgical unit is planning care for assigned clients. Which of the following
actions should the nurse plan to take to demonstrate effective time management?
, ◯ Delay cleaning personal work area until the end of the shift.
◯ Gather supplies for a client’s dressing change and technology check.
◯ Document assessment findings and interventions after providing care for a group of clients.
◯ Complete activities for one client before moving to the next client.
Correct Answer:
t
Complete activities for one client before moving to the next client.
ne
Explanation:
Focusing on completing activities for one client at a time ensures that the nurse provides safe and
thorough care without missing steps or details, which is key to effective time management.
sh
Question 5 of 180
A nurse is planning care for a client who is scheduled to receive a peripherally inserted central
catheter in the arm. Which of the following interventions is appropriate for the nurse to include in
the plan of care?
◯ Administer sedation for the procedure.
la
◯ Use gauze to secure an arm board to the involved extremity.
◯ Schedule an MRI postprocedure to verify placement.
◯ Measure the arm circumference above the insertion site daily.
Sp
Correct Answer:
Measure the arm circumference above the insertion site daily.
Explanation:
Measuring arm circumference daily is important to monitor for complications such as swelling,
which can indicate infection or thrombus formation.
Question 6 of 180
A nurse is caring for a client in an outpatient clinic.
, Laboratory Results
First office visit:
Erythrocyte sedimentation rate (ESR) 22 mm/hr (up to 20 mm/hr)
Hct 36% (37 to 47%)
Hgb 12 g/dL (12 to 16 g/dL)
WBC count 6000/mm³ (5,000 to 10,000/mm³)
t
Uric acid 6.1 mg/dL (2.7 to 7.3 mg/dL)
ne
6-month follow-up:
Erythrocyte sedimentation rate (ESR) 22 mm/hr (up to 20 mm/hr)
Antinuclear antibodies (ANA) positive
Hct 35% (37 to 47%)
Hgb 11 g/dL (12 to 16 g/dL)
sh
WBC 4000/mm³ (5,000 to 10,000/mm³)
Uric acid 6.3 mg/dL (2.7 to 7.3 mg/dL)
Complete the following sentence by using the lists of options.
The client is at highest risk for developing Select ___________ evidenced by the client’s Select
la
__________.
Correct Answer:
The client is at highest risk for developing lupus evidenced by the client’s positive ANA test.
Sp
Explanation:
A positive ANA test is a common indicator of systemic lupus erythematosus (SLE), an
autoimmune disorder.
Question 7 of 180
A nurse is caring for a 36-hr old infant.
Nurses’ Notes
24 hr of age: