Guide – Practice Questions
with Verified Answers
Rationales. GRADED A+. Latest
2026/2027 Update.
A nurse is caring for a client who is postoperative following abdominal surgery.
Exhibit 1
Nurses' Notes 1100:Client received from PACU; initial vital signs recorded.
Client drowsy but responds to verbal stimuli. Client is oriented to person, place,
and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal
dressing intact with drainage noted and marked. Indwelling urinary catheter in
place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the
right forearm. Client positioned for comfort, side rails raised x 2, call light in the
client's reach.1115:Provider prescriptions reviewed.1200:Upon waking, client
reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing
intact, no further drainage noted. - Answer✔✔-Click to highlight the
assessment findings below that the nurse should report to the provider. To
deselect a finding, click on the finding again.
***Urinary output***
***Reported pain level***
***Vital signs***
,Neurological assessment is incorrect. The client is oriented to person, place,
and time. They are able to move all extremities and have no obvious indication
of neurological compromise.
Incisional drainage is incorrect. While the initial assessment indicated drainage
on the dressing, there has been no further drainage since that time. A small
amount of drainage following abdominal surgery is an expected finding and
does not need to be reported to the provider unless drainage continues or
increases over time.
Urinary output is correct. A client who has an indwelling urinary catheter
should produce at least 30 to 50 mL/hr of urine. The client's output is less than
the expected volume. The nurse should assess the catheter's placement and
potential for blockage due to their reduced urine output. This finding should be
reported to the provider.
Reported pain level is correct. The client's pain has not been relieved with the
administration of morphine. According to the client's report, their pain level is
increasing. This finding should be reported to the provider.
Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel
sounds were initially noted, the client reports relief after the administration of
metoclopramide.
Vital signs is correct. The client's heart rate and respiratory rate have increased,
and their blood pressure and oxygen saturation levels have decreased. These
findings should be reported to the provider.
A nurse is caring for a client who reports difficulty falling asleep. Which of the
following recommendations should the nurse make? - Answer✔✔-"Maintain a
consistent time to wake up each day."
Rationale: The client should maintain a consistent time for waking up and
going to sleep. This helps to establish an internal sense of sleep and waking on
a daily basis and helps to maintain it over time. This will help promote sleep for
the client.
, A nurse is caring for a client who has diarrhea due to shigella. Which of the
following precautions should the nurse implement for this client? -
Answer✔✔-Wear a gown when caring for the client.
Rationale: The nurse should implement contact precautions for a client who
has shigella to prevent the transmission of the bacteria. The nurse should wear
a gown when providing care for a client who requires contact precautions due
to the risk of contact with bodily fluids and contaminated surfaces.
A nurse is assessing a client who reports increased pain following physical
therapy. Which of the following questions should the nurse ask when assessing
the quality of the client's pain? - Answer✔✔-"Is your pain sharp or dull?"
Rationale: Asking the client whether the pain is sharp, dull, crushing,
throbbing, aching, burning, electric-like, or shooting helps determine the
quality of the pain.
A nurse in a surgical suite notes documentation on a client's medical record
that they have a latex allergy. In preparation for the client's procedure, which of
the following precautions should the nurse take? - Answer✔✔-Wrap
monitoring cords with stockinette and tape them in place.
Rationale: Many monitoring devices and cords contain latex. The nurse should
prevent any contact of these cords and devices with the client's skin by
covering them with a nonlatex barrier material, such as stockinette, and using
nonlatex tape to secure them.