2025\2026 A+ Grade
The nurse knows that which statement by the mother indicates that the mother understands safety
precautions with her four month-old infant and her 4 year-old child?
- correct answer "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen
while I make supper."
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have
an advance directive. What action should the nurse take?
- correct answer Give information about advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the
immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty
breathing. The nurse expects that the first action in the sequence of care for this client will be to
- correct answer Administer epinephrine 1:1000 as ordered
Which of these children at the site of a disaster at a child day care center would the triage nurse put in
the "treat last" category?
- correct answer A toddler with severe deep abrasions over 98% of the body
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission
form. In the event these do not match, the nurse's best action is to
- correct answer Notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was written right
before the shift change. What action should be taken?
- correct answer Call the provider for clarification
,An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and
calling for help, the next action that should be taken by the nurse is to:
- correct answer open the client's airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has
been infused after 4 hours. What is the priority nursing action?
- correct answer Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- correct answer 72 year-old recovering from surgery after a hip replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the client lie on the left
side for the administration. The family member pushed the suppository until the finger went up to the
second knuckle. After 10 minutes the client was told by the family member to turn to the right side and
the client did this. What is the appropriate comment for the nurse to make?
- correct answer That was done correctly. Did you have any problems with the insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of
precautions is the appropriate type to use when performing postmortem care?
- correct answer contact precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is
appropriate teaching?
- correct answer clean the meatus, begin voiding, then catch urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these
foods would the nurse reinforce for the client to eat at least daily?
- correct answer watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?
- correct answer Immediately wash the hands with vigor
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection,
the nurse notes that the student begins to give the medication without first aspirating. What should the
, nurse do?
- correct answer Walk up and whisper in the student's ear "Stop. Aspirate. Then inject."
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's condition?
- correct answer Glascow Coma Scale 8, respirations regular
A client enters the emergency department unconscious via ambulance from the client's work place.
What document should be given priority to guide the direction of care for this client?
- correct answer A notarized original of advance directives brought in by the partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP)
and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
- correct answer An admission at the change of shifts with atrial fibrillation and heart failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all
the time and has a lot of gas. The nurse expects to find which of the following on the initial history and
physical assessment?
- correct answer Restlessness and increased mucus production
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require
follow-up and are consistent with the diagnosis?
- correct answer "Clothes are becoming tighter across her abdomen."
A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally
married and signs the consent form for treatment. What would be the appropriate action by the nurse?
- correct answer Proceed with the triage process in the same manner as any adult client
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is
appropriate to assign to an unlicensed assistive personnel (UAP)?
- correct answer Report hourly outputs of less than 30 ml/hr
The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by
the parent would cause the nurse to suspect an association with this disease?
- correct answer Strep throat went through all the children at the day care last month.