2026–2027 Verified Questions & Answers
A nurse is caring for an older adult client who has kidney failure. The client tells the nurse that she has
decided to stop hemodialysis treatment. Which of the following actions by the nurse is appropriate in
regard to serving as the client's advocate? - correct answers -Supporting the client's decision regarding
treatment
-The nurse's role as client advocate is to support the client's decision to discontinue treatment.
A nurse is caring for an older adult client. The client received 0.9% sodium chloride 1 L over 4 hr instead
of over 8 hr as prescribed. Which of the following entries is the appropriate documentation of this
occurrence in the client's medical record? - correct answers -0.9% sodium chloride 1 L IV infused over 4
hr. Vital signs stable.- The nurse should document the amount of fluid, how long it took to infuse, and
the client's physical status.
When planning care for a child who has increased intracranial pressure (ICP), which of the following
should the nurse include in the child's plan of care? - correct answers -Maintain head in midline. -The
child's head should be maintained in a midline position to promote venous return and prevent an
increase in ICP.
- correct answers -Sleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an
indication of increased ICP.//
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent
decrease in diastolic blood pressure) is an indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP.
A nurse is talking with a client who is beginning chemotherapy. She tells the nurse that she is mourning
the loss of her hair. Which of the following actions should the nurse take first? - correct answers -
Discuss the importance of hair with the client.--The first action the nurse should take using the nursing
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,process is to assess the client. By identifying the importance of hair to the client, the nurse can
acknowledge the importance of the expected loss to the client and assist the client with anticipatory
grieving.
- correct answers -an inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require planning and math skills, such as
managing finances.
- correct answers -Fine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.
- correct answers -Discontinue the infusion.--A report of pain and a red line extending outward from
the insertion site are manifestations of phlebitis and indicates that the client is at the greatest risk from
injury to the vein; therefore, the first action the nurse should take is to discontinue the infusion.
A client who is being discharged today asks the nurse for supplies for her wound dressing. Which of the
following actions should the nurse take to ensure quality, cost-effective care? - correct answers -Provide
enough supplies for 1 to 2 days.-Although wound care supplies for home use are typically purchased by
clients after leaving the facility, it may be necessary to provide adequate supplies for the immediate
discharge period.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the following should
the nurse document as a therapeutic outcome? - correct answers -Decrease in flexor and extensor
spasticity-
Baclofen decreases the frequency and severity of muscle spasms, allowing for improved muscle
function.
A nurse is providing postoperative instructions about complete proteins to a client following a below-
the-knee amputation. Which of the following food choices indicates a need for additional instruction? -
correct answers -Pinto beans-
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, Pinto beans are a plant protein; therefore, this food choice is an incomplete protein.
A community health nurse is asked to give a health education program to a group of African-American
men age 40 to 75. Considering the health concerns of this group, which of the following topics is most
important to include in the program? - correct answers -Prostate cancer screening-
The greatest risk for African-American males is death from prostate cancer. Therefore, prostate cancer
screening is the priority topic to include.
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT). The provider
has explained the procedure to the client. Which of the following statements made by the client
indicates a need for further teaching? - correct answers -"This procedure can increase my risk for
developing Parkinson's disease."-
Developing Parkinson's disease is not an adverse effect of ECT; therefore, this statement indicates a
need for further teaching.
A nurse is caring for a client who has an ileostomy and is 4 weeks postoperative. The client reports
leakage and irritation around the stoma. Which of the following is an appropriate intervention? - correct
answers -Instruct the client to use a skin barrier when refitting the pouch system.-
The client should use a skin barrier to protect the skin from enzymes and bile salts from gastrointestinal
drainage at the stoma site.
A nurse is educating a client who is at 30 weeks of gestation regarding a 3-hr oral glucose tolerance test.
Which of the following should the nurse include in her teaching? - correct answers -Consume 150 g of
carbohydrates daily for 3 days prior to the test.-
A carbohydrate load prior to the glucose tolerance test is necessary for an accurate assessment.
A client with a diagnosis of depression is attending group therapy. During the group meeting, the nurse
asks each member to identify one goal for the day. When it is the client's turn, she does not respond.
Which of the following should the nurse do before repeating the request to the client? - correct answers
-Allow the client time to collect her thoughts. -
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