Questions 2026 Exam All
Answers and Illustrations
Given
A client who reports shortness of breath requests her nurse's help in
changing positions. After repositioning the client, which of the following
actions should the nurse take next?
a. Encourage the client to take deep breaths.
b. Observe the rate, depth, and character of the client's respirations.
c. Prepare to administer oxygen.
,d. Give the client a back rub to help her relax. - ANSWER
✔✔Observe the rate, depth, and character of the client's respirations.
The nurse should apply the nursing process priority-setting framework
when caring for this client. The nurse can use the nursing process to
plan client care and prioritize nursing actions. Each step of the nursing
process builds on the previous step, beginning with assessment or data
collection. Before the nurse can formulate a plan of action, implement a
nursing intervention, or notify a provider of a change in the client's
status, the nurse must first collect adequate data from the client.
Assessing or collecting additional data will provide the nurse with
knowledge to make an appropriate decision; therefore, the first action
the nurse should take is to assess the client's respiratory status.
A nurse is caring for a client who, while sitting in a chair, starts to
experience a seizure. Which of the following actions should the nurse
take?
a. Place a padded tongue blade in the client's mouth.
b. Lower the client to the floor and place a pad under the client's head.
c. Seek the help of a coworker and lift the client back into bed.
,d. Use an oropharyngeal airway to keep upper airway passages open. -
ANSWER ✔✔Lower the client to the floor and place a pad under the
client's head.
To reduce the risk of injury to the client, the nurse should lower the client
to the floor and place a pillow or other soft object under the client's head.
A home health nurse is planning to provide health promotion activities for
a group of clients in the community. Which of the following activities is an
example of the nurse promoting primary prevention?
a. Teaching clients to perform self-examinations of breasts and testicles
b. Educating clients about the recommended immunization schedule for
adults
c. Teaching clients who have type 1 diabetes mellitus about care of the
feet
d. Recommending that clients over the age of 50 have a fecal occult
blood test annually - ANSWER ✔✔Educating clients about the
recommended immunization schedule for adults
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, Primary prevention includes health education about disease prevention.
A nurse is using the I-SBAR communication tool to provide the client's
provider with information about the client. The nurse should convey the
client's pain status in which portion of the report?
a. Assessment
b. Background
c. Situation
d. Recommendation - ANSWER ✔✔Assessment
The nurse provides information about assessment findings in this portion
of the report. This includes vital signs, pain assessment, and changes in
assessment findings.
A nurse is caring for a client who is receiving IV therapy via a peripheral
catheter. The nurse should identify that which of the following findings is
an indication of infiltration?
a. Redness at the infusion site