ANSWER GUIDE AND EXPLANATIONS 2026
◉ Nurse implementation when using active listening skills Answer: -
Pay attention
- Show that you are listening
- Provide feedback
- Defer judgement
- Respond appropriately
◉ The importance of isolation measures for patient with airborne
precautions Answer: Isolation: The process or fact of isolating or
being isolated.
Airborne isolation: protective measures against droplet infections
smaller than 5mcg
◉ Proper order of the PPE (put on and remove) Answer: Removal
(DOFF): Gloves, goggles/face shield, gown, mask
On (DON): Gown, mask/respirator, googles/face shield,
gloves*Gloves
,◉ Pulse assessments (Review the most important pulses reviewed
during class/where you can find them) Answer: Temporal, Carotid,
brachial, radial, femoral, popliteal, dorsal is pedis, and posterior
tibial
◉ The nurse is caring for a client who is having a colonoscopy. The
client states, "I am so nervous about what the doctor might find
during the test." The nurse responds by saying: "Are you feeling
anxious about the results of your colonoscopy?" The nurse's
response is an example of which of the following communication
techniques? Answer: Clarification
◉ A nurse is completing a client's history and physical examination.
Which information should the nurse consider subjective data?
Answer: Nausea
◉ A nurse is responsible to check that an assistive personnel (AP)
uses appropriate personal protection equipment while caring for
clients. Which of the following statements made by the AP indicates
an appropriate understanding of standard precaution techniques?
Answer: "I will wear gloves and gown when bathing a client who has
open skin lesions."
◉ The patient at greatest risk for developing multiple adverse
effects of immobility is a? Answer: B. 80-year-old woman who has
suffered a hemorrhagic cerebrovascular accident (CVA).
,◉ When assessing peripheral vascular status of the lower
extremities, you place your fingertips on the top of your patient's
foot between the extensor tendons of the great toe and those of the
toe next to it. Which pulse are you palpating? Answer: Dorsalis pedis
◉ The nurse puts elastic stockings (TED Hose) on a patient
following major abdominal surgery. The nurse teaches the patient
that the stockings are used after a surgical procedure to? Answer:
Promote venous return to the heart.
◉ A nurse is about to use the Wong-Baker FACES pain scale to assist
a patient in assessing his pain level. Which of the following should
the nurse know in order to use this pain scale? Pick all that apply.
Answer: This scale is useful for adult patients who have cognitive
impairments
◉ The nurse is educating a caregiver on hygiene. Which statement
by the caregiver would Indicate that she needs further education?
Answer: A client's cultural background does not influence hygiene
needs
◉ When the nursing assistive personnel is giving a complete bed
bath to a client and is starting
the perineal care, the nursing assistive personnel explains to the
client that the term
, "perineal care" is? Answer: Cleansing patients' genital and anal areas
◉ The nurse is doing a physical examination on her client. Which
one below is considered
outside the scope of practice when doing physical exams? Answer:
To apply personal biases
◉ When using the inspection technique during a physical
examination, the nurse? Answer: Uses vision to recognize normal
and abnormal
◉ The nurse is planning to teach the student nurse how to assess
the hydration status (fluid
status) of an adult. Which technique is appropriate for this
situation? Answer: Assessing skin turgor by pinching a fold of skin
on the sternum near clavicle
◉ The nurse knows that the type and amount of exercise or work
that a person is able to
perform is known as? Answer: Activity tolerance
◉ Which vital sign is of priority for your nursing interventions?
Answer: Oxygen saturation (SpO2) = 89%