VERIFIED QUESTIONS AND ANSWERS||
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LATEST UPDATE 2025
A 46 year old male client who had a myocardial infarction (MI) 24 hours ago
comes to the nurses station fully dressed and wanting to go home. He tells the
nurse that he is feeling much better at this time. Based on this behavior, which
client problem should the nurse include in the plan of care?
a. Deficient knowledge of lifestyle changes
b. Decisional conflict due to stress
c. Anxiety related to treatment plan
d. Ineffective coping related to denial - ANSWER-d. Ineffective coping related
to denial
The nurse observes a client prepare a meal in the kitchen of a rehabilitation
facility prior to discharge. Which behaviors indicate the client understands how
to maintain balance safety? Select all that apply.
a. Leans forward to pull a pan from a high shelf
b. Bends from the waist to pick trash off the floor
c. Locks knees while preparing food on the counter
d. Brings a heavy can close to body before lifting
e. Widens stance while working near the sink - ANSWER-d. Brings a heavy can
close to body before lifting
e. Widens stance while working near the sink
,The client arrives on the surgical floor after a major abdominal surgery.
Which intervention should the nurse perform first?
a. Determine the client's vital signs
b. Assess the surgical site
c. Apply warm blankets
d. Administer prescribed pain medication - ANSWER-a. Determine the client's
vital signs
An older client comes to the clinic with a family member. When the nurse
attempts to take the clients health history, the client does not respond to the
questions in a clear manner. What action should the nurse implement first?
a. Provide a printed healthcare assessment form
b. Assess the surroundings for noise and distractions
c. Ask the family member to answer the questions
d. Defer the health history until the client is less anxious - ANSWER-b. Assess
the surroundings for noise and distractions
An older client arrives to the emergency department with reports of severe
nausea and vomiting large amounts of liquid brown emesis at home. The client's
vital signs are temperature of 95.4 degrees F, heart rate 112 beats/minute,
respiration 14 breaths/minute, and blood pressure 74/37 mmhg. Which
intervention is most important for the nurse to implement?
a. Maintain strict intake and output
b. Monitor blood glucose level
c. Keep head of bed raised 45 degrees
d. Assess warmth of extremities - ANSWER-c. Keep head of bed raised 45
degrees
,The nurse is preparing to administer an IV dose of ciprofloxacin to a client with
a urinary tract infection. Which client data requires the most immediate
intervention by the nurse?
a. White blood cell count of 12,000 mm^3 (12 x 10^9/L)
b. Urine culture positive for MRSA
c. Serum sodium of 145 meq/L (145 mmol/L)
d. Serum creatinine of 4.5 mg/dl (398 mcmol/L) - ANSWER-d. Serum
creatinine of 4.5 mg/dl (398 mcmol/L)
The nurse is caring for a client who is receiving continuous ambulatory
peritoneal dialysis (CAPD) and notes that the urine output flow is 100 ml less
than the input flow. Which action should the nurse implement first?
a. Irrigate the dialysis catheter
b. Check the client's blood pressure and serum bicarbonate
c. Change the client position
d. Continue to monitor and take an output with next exchange - ANSWER-d.
Continue to monitor and take an output with next exchange
A client in menopause reports being lactose intolerant. She exercises three times
a week, drinks wine one to three times a month, and drinks a cup of coffee
daily. Which instruction should the nurse provide to the client to reduce her risk
of developing osteoporosis?
a. Increase weekly exercise
b. Increase calcium intake
c. Decrease wine consumption
d. Decrease coffee consumption - ANSWER-b. Increase calcium intake
, During discharge teaching, a male client recently diagnosed with malignant
hypertension tells the nurse that he really enjoys downhill skiing and asks if he
can continue with this sport. Which is the best response by the nurse?
a. "It should be alright as long as you can find your skiing to the easier trails."
b. "Go for it. Skiing should provide you with a terrific aerobic workout."
c. "Cold weather may constrict your blood vessels raising your blood pressure'"
d. "Skiing might produce too much exertion. How about sledding?" -
ANSWER-c. "Cold weather may constrict your blood vessels raising your blood
pressure'"
After initiating a blood pressure cuff and releasing the valve, the nurse hears
silence followed by a Korotkoff sound. What action should the nurse take next?
a. Note the presence of an auscultatory gap
b. Reinflate the cuff to a higher number
c. Reposition the stethoscope over the brachial artery
d. Continue with the blood pressure assessment - ANSWER-a. Note the
presence of an auscultatory gap
Choice A rationale:
Continue with the blood pressure assessment. Continuing with the blood
pressure assessment without addressing the observed auscultatory gap could
lead to an inaccurate reading. It's important to investigate and note the presence
of an auscultatory gap before proceeding with the assessment.
Choice B rationale:
Reposition the stethoscope over the brachial artery. Repositioning the
stethoscope may not resolve the issue of hearing silence followed by a
Korotkoff sound. It is important to assess the situation further before making
adjustments.
Choice C rationale: