Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which
intervention is appropriate?
A. Increase the rate if the client is short of breath
B. ✔✔Check the skin behind the ears for irritation
C. Remove the cannula every hour
D. Apply an oil-based moisturizer to nostrils
A nurse is reinforcing teaching with a client who is at risk for constipation. Which instruction
should the nurse give?
A. Avoid fiber-rich foods
B. Drink fluids only when thirsty
C. ✔✔Increase activity level
D. Limit fresh fruit intake
A nurse is preparing to administer a medication to a client via a gastrostomy tube. What should
the nurse do first?
1
,A. ✔✔Verify tube placement
B. Crush all medications together
C. Mix medications with tube feeding formula
D. Administer without flushing
A nurse is reviewing a client’s fluid intake and output. What finding should the nurse report?
A. Output is greater than intake
B. ✔✔Output is less than 30 mL/hr
C. Intake and output are balanced
D. Output is slightly more than intake
A nurse is caring for a client who requires droplet precautions. What action should the nurse
take?
A. Wear gloves only
B. ✔✔Wear a mask within 3 feet of the client
C. Use a HEPA filter
D. Maintain airborne precautions
2
,A nurse is collecting data from a client who has a stage 2 pressure injury. What is expected?
A. ✔✔Partial-thickness skin loss with exposed dermis
B. Intact skin with nonblanchable redness
C. Full-thickness skin and tissue loss with slough
D. Muscle and bone exposed
A nurse is caring for a client who is on a pureed diet. Which food should the nurse offer?
A. Crackers
B. ✔✔Applesauce
C. Toast
D. Fried chicken
A nurse is preparing to give an intramuscular injection to an adult. Which site is most
appropriate?
A. Deltoid if dose is large
B. ✔✔Ventrogluteal
C. Dorsal hand vein
D. Inner thigh
3
, A nurse is reinforcing teaching to a client about using a walker. Which client statement indicates
understanding?
A. I’ll use it on the stairs
B. ✔✔I will move the walker forward before stepping
C. I will carry the walker
D. I can use it to support my full weight
A nurse is assisting a client who is experiencing difficulty sleeping. Which action should the
nurse take?
A. Provide a heavy meal at bedtime
B. ✔✔Offer a warm drink without caffeine
C. Encourage TV watching all night
D. Suggest vigorous exercise before bed
A nurse is collecting data from a client who has fluid overload. Which of the following is an
expected finding?
A. Hypotension
B. ✔✔Crackles in lungs
4