Questions and Answers 2025
A home health nurse is caring for a child who has Lyme disease. Which of the following
is an appropriate action for the nurse to take? - CORRECT ANSWERS-
Ensure the state health department has been notified.
A nurse is caring for a clientAwho has a vented NG tube set to low intermittent suction a
nd has vomited. Which of the following actions should the nurse perform first? -
CORRECT ANSWERS-Evaluate functioning of the suction device.
While performing a routine assessment, a nurse notices fraying onto the electrical cord
of a client's continuous passive motion (CPM)device. Which of the following actions sho
uld the nurse take first? - CORRECT ANSWERS-Remove the device from the room.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the f
ollowing actions should the nurse take when pouring the sterile solution? -
CORRECT ANSWERS-Remove the cap and place it sterile side up on a clean surface.
A nurse is creating a plan of care for a female client who has recurrent urinary tract infe
ctions. Which of the following interventions should the nurse include in the plan? -
CORRECT ANSWERS-Wear loose fitting underwear.
A nurse is caring for an infantAwho has gastroenteritis. Which of the following assessme
nts findings should the nurse report to the provider? - CORRECT ANSWERS-
Sunken fontanels and dry mucous membranes.
A nurse is conducting health promotion education regarding contraindications to combin
ation oral contraceptive use to a group of women. Which of the following conditions sho
uld the nurse include in the teaching? - CORRECT ANSWERS-Hypertension
A nurse is providing teaching to a client who has a depressive disorder and a new presc
ription for amitriptyline. Which of the following statements by the client indicates underst
anding of the teaching? - CORRECT ANSWERS-
"I know itAwill be a couple of weeks before the medication helps me feel better."
A nurse is caring for a clientAwho is immobile. Which of the following interventions is app
ropriate to prevent contracture? - CORRECT ANSWERS-
Align a trochanter wedge between the client's legs.
A nurse is assessing a client who is postoperative following abdominal surgery and has
an indwelling urinary catheter that is draining darkAyellow urine at 25 mL/hr. Which of th
e following interventions should the nurse anticipate? - CORRECT ANSWERS-
Obtain a urine specimen for culture and sensitivity
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for t
he client's daily warfarin. Which of the following laboratory tests should the nurse plan to
report to obtain the prescription for the warfarin? - CORRECT ANSWERS-INR
A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparki
nsonism. Which of the following findings should the nurse document as a manifestation
of pseudoparkinsonism? - CORRECT ANSWERS-Shuffling gait
A nurse is caring for a clientAwho is experiencing expressive aphasia and right hemipare
sis following a stroke. Which of the following actions by the nurse best promotes commu
, nication among staff caring for the client? - CORRECT ANSWERS-
Having interdisciplinary team meetings for the clientAon a regular basis.
A nurse is caring for a 2-year-
old toddler. Which of the following food choices should the nurse recommend to promot
e independence in eating? - CORRECT ANSWERS-Banana slices
A nurse on a medical-
surgical unit is notified that a mass casualty event has occurred in the community. Whic
h of the following actions should the nurse plan to take? - CORRECT ANSWERS-
Recommend to the provider specific acute care clients for discharge.
A nurse is receiving change-of-
shift report for four clients. Which of the following clients should the nurse assess first? -
CORRECT ANSWERS-
A client who was just given a glass of orange juice for low blood glucose level.
A nurse is performing postmortem care for a recently deceased client prior to the client's
family visit. Which of the following actions should the nurse plan to take? -
CORRECT ANSWERS-Hold the client's eyes shut for a few seconds.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voice
s." Which of the following responses is the priority for the nurse to state? -
CORRECT ANSWERS-"What are the voices telling you?"
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. T
he nurse should recognize which of the following as an indication that the medication ha
s been effective? - CORRECT ANSWERS-Weight loss
A nurse is caring for a clientAwho requires nasotracheal suctioning. Identify the sequenc
e the nurse should follow to perform suctioning. - CORRECT ANSWERS-
1. Turn on the suction and set the pressure.
2. Don sterile gloves.
3. Insert the catheter during the client's inspiration.
4. Apply suction while rotating the catheter.
5. Rinse the catheter to remove secretions.
A nurse is caring for a clientAwho is in a coma and is scheduled for a surgical procedure.
Which of the following actions should the nurse take? - CORRECT ANSWERS-
Determine if the client's health care surrogate is aware of the risks and benefits of the pr
ocedure.
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the
nurse if the medication can be given 2 hours earlier. Which of the following statements s
hould the nurse make? - CORRECT ANSWERS-
"I can start the medication 30 minutes earlier."
A nurse is caring for a clientAwho requires seclusion to prevent harm to others on the uni
t. Which of the following is an appropriate action for the nurse to take? -
CORRECT ANSWERS-Offer fluids every 2 hours.
A nurse is caring for an adolescent who has hyperthermia. Which of the following action
s should the nurse take? - CORRECT ANSWERS-Initiate seizure precautions.
A nurse is caring for a clientAwho asks for information regarding organ donation. Which
of the following responses should the nurse make? - CORRECT ANSWERS-
"Your desire to be an organ donor must be documented in writing."