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(35 Questions, Expert Answers, and
Explanations) Latest Update 2026
Question one,
A nurse is caring for a client with a new prescription for warerin. Which client statements
indicate a need for further teaching about this medication? Select all that apply.
A I will take aspirin for any headaches I get.
B. I can continue to eat my large spinach salads daily.
C. I will use an electric razor for shaving.
D. I need to report any unusual bruising or bleeding.
E. I should keep my appointments for blood tests regularly.
F. I will double my dose if I forget to take it one day.
Answer. I will take aspirin for any headaches I get. I can continue to eat my large spinach
salads daily. I will double my dose if I forget to take it one day.
This question tests understanding of essential client education regarding warerin and anti-
coagulant. The key phrase need for further teaching indicates an incorrect statement. Aspirin
increases bleeding risk when taken with warerin. Large amounts of vitamin K rich foods like
spinach can decrease warerin's effectiveness and doubling a dose after a mist one significantly
increases bleeding risk. For instance, a client taking ibuprofen for pain while on warpherin could
experience severe gastrointestinal bleeding. Remember that warerin management requires
strict adherence to dosing, careful monitoring, and awareness of drug and food interactions to
prevent complications.
Question two,
A nurse is assessing a client admitted with fluid volume overload. Which findings should the
nurse expect? Select all that apply.
A I flat jugular veins.
B Bounding peripheral pulses.
C. Decreased urine output.
D. Distended neck veins.
E. Crackles in the lungs.
F. Orthostatic hypotension.
Answer: Bounding peripheral pulses, distended neck veins, crackles in the lungs.
This item evaluates the nurse's ability to recognize manifestations of fluid volume overload, a
condition where the body retains too much fluid. Key findings include bounding peripheral
pulses due to increased circulatory volume, distended neck veins indicating increased central
venus pressure, and crackles in the lungs, pulmonary edema resulting from fluid shifting into the
,alvear spaces. For example, a client with fluid overload might also report shortness of breath
and have visible swelling in their ankles. Always remember that signs of fluid excess often relate
to increased pressure and fluid accumulation in dependent areas or the lungs.
Question three.
The nurse is preparing to administer medications through a nasogastric NG tube. Which actions
are appropriate? Select all that apply.
A I crush all medications thoroughly before administration.
B. Check for placement of the NG tube before administering medications.
C. Aspirate stomach contents to check residual volume.
D. Mix all crushed medications together in one syringe.
E. Flush the tube with 15 to 30 ml of water before and after medication administration.
F. Return aspirated stomach contents to the client after checking residual volume.
Answer: Check for placement of the NG tube before administering medications. Flush the
tube with 15 to 30 ml of water before and after medication administration. Return
aspirated stomach contents to the client after checking residual volume.
This question focuses on safe medication administration via a nasogastric tube. The core
concept is preventing aspiration and ensuring proper drug delivery. Verifying tube placement is
critical to prevent medications from entering the lungs. Flushing the tube prevents clogging and
ensures full dose delivery. And returning aspirated contents helps maintain fluid and electrolyte
balance. For example, if tube placement isn't checked, medication might be inadvertently
instilled into the trachea, leading to aspiration pneumonia. Always prioritize patient safety by
confirming tube location and maintaining tube patency and physiological balance.
Question four.
A client is prescribed a clear liquid diet. Which food items are appropriate for the nurse to offer?
Select all that apply.
A I. Cream of mushroom soup.
B. Gelatin.
C. Apple juice.
D. Sherbet.
E. Coffee with cream.
F. Chicken broth.
Answer. Gelatin. Apple juice. Chicken broth.
This question assesses knowledge of appropriate food items for a clear liquid diet, which
includes liquids that are transparent and easily digestible. Items like gelatin, apple juice without
pulp, and chicken broth are suitable because they are clear at room temperature and leave
minimal residue in the gastrointestinal tract. Conversely, cream soups, sherbet, and coffee with
cream are not considered clear liquids due to their opacity and higher fat or particulate content.
For instance, a patient preparing for a colonoscopy might be restricted to clear liquids to ensure
the bowel is thoroughly cleansed. Remember, if you can see through it, it's likely a clear liquid.
, Question five.
The nurse is providing discharge teaching to a client diagnosed with heart failure. Which
instructions should the nurse include? Select all that apply?
A I weigh yourself daily at the same time.
B. Restrict sodium intake to 2 g per day.
C. Report a weight gain of 2 lbs or more in 24 hours.
D. Increase fluid intake to at least 3 L daily.
E. Elevate legs when sitting to promote Venus return.
F. Avoid taking diuretics to prevent dehydration.
Answer. Weigh yourself daily at the same time. Restrict sodium intake to 2 grams per
day. Elevate legs when sitting to promote Venus return.
This question tests the nurse's understanding of discharge teaching for heart failure
management. Focusing on self-care to prevent exacerbations. Daily weight monitoring at the
same time helps detect fluid retention early. Sodium restriction minimizes fluid retention and
elevating legs reduces peripheral edema by promoting venus return. For example, a client who
gains several pounds overnight might be retaining fluid and needs to contact their provider, not
increase their fluid intake. Emphasize that careful monitoring of weight, diet, and symptoms is
paramount in managing chronic heart failure effectively.
Question six,
a nurse is providing care for a client experiencing an acute asthma exacerbation. Which actions
should the nurse prioritize? Select all that apply.
A I administer a prescribed bronco dilator.
B. Place the client in a high fowler's position.
C. Initiate continuous pulse oxymmetry monitoring.
D. Administer supplemental oxygen.
E. Assess lung sounds frequently.
F. Obtain a detailed history of allergen exposure.
Answer. Administer a prescribed broncoilator. Place the client in a high fowler's position.
Initiate continuous pulse oximry monitoring. Administer supplemental oxygen. Assess
lung sounds frequently.
This question assesses prioritization of nursing interventions during an acute asthma
exacerbation. The keywords acute and prioritize indicate the need for immediate life sustaining
actions. Administering a bronco dilator, positioning the client to optimize breathing, monitoring
oxygen saturation, providing supplemental oxygen, and assessing lung sounds are all critical
immediate interventions aimed at improving ventilation and oxygenation. While obtaining an
allergen history is important, it is not an immediate life-saving priority during an acute crisis.
Always remember to prioritize the ABCs, airway, breathing, circulation in emergent situations to
stabilize the client's condition.
Question seven.