ANSWERS RATIONALES ( VERIFIED ANSWERS)\ ALREADY GRADED A+/ LATEST
VERSION 2024
A client with a history of hypertension has been prescribed a newantihypertensive medication and
is reporting dizziness. Which is the best way for the nurse to assess blood pressure?
You Selected:
in the supine, sitting, and standing positions
Correct response:
in the supine, sitting, and standing positions
A client has a soft wrist-safety device. Which assessment findingshould the nurse investigate
further?
You Selected:
Question 2
.” The nurse is making a room assignment for a client whose laboratory test result indicate
pancytopenia. Which client should thenurse put into the same room with the client with
pancytopenia?
You Selected:
a client with digoxin toxicity
Correct response:
a client with digoxin toxicity
Question 3
A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell
(WBC) count, especially the neutrophil count, is low. What is the most important intervention the
,nurse should teach the parents?
You Selected:
Protect your child from infections because his resistance toinfection is decreased
Correct response:
Protect your child from infections because his resistance toinfection is decreased
Question 4
The nurse is caring for a client with influenza. The most effectiveway to decrease the spread of
microorganisms is:
You Selected:
placing the client in isolation.
Correct response:
washing the hands frequently.
Question 5
A school-age client with diabetes is placed on an intermediate-acting insulin and regular insulin
before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What
does the nurse tell the client the snack is intended to do?
You Selected:
Prevent late night hypoglycemia.
Correct response:
Prevent late night hypoglycemia.
cool, pale fingers
Correct response:
cool, pale fingers
Question 7
A nurse is caring for a female client before surgery. The client statesthat she is glad that she will
not be going through menopause as a result of her surgery and is only having her uterus removed.
The nurse reviews the consent form and notes that the surgery is for a total abdominal
hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation?
You Selected:
Contact the surgeon to explain that the client needs furtherclarification regarding surgery.
Correct response:
Contact the surgeon to explain that the client needs furtherclarification regarding surgery.
Question 8
A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when
I thought everyone was out to getme, I was staying in my apartment all the time. Now, I would like
toget out and do things again." What is the best initial response by thenurse?
You Selected:
"What activities did you enjoy in the past?"
Correct response:
"What activities did you enjoy in the past?"
,Question 9
A client with anemia has been admitted to the medical-surgical unit.Which assessment findings are
characteristic of iron deficiency anemia?
You Selected:
nausea, vomiting, and anorexia
Correct response:
dyspnea, tachycardia, and pallor
Question 10
The nurse is discontinuing an intravenous catheter on a 10-year-oldclient with hemophilia. What
would be the most important intervention for this client?
You Selected:
Apply firm pressure on the site for 5 minutes after removal.
Correct response:
Apply firm pressure on the site for 5 minutes after removal.
Question 11
When a client returns from the recovery room postmastectomy, an initial postoperative assessment
is performed by the nurse. What is the nurse’s priority assessment?
You Selected:
checking the dressing, drain, and amount of drainage
Correct response:
assessing the vital signs and oxygen saturation levels
Question 12
, A client with an uncomplicated term pregnancy arrives at the labor- and-delivery unit in early labor
saying that she thinks her water has broken. What is the nurse’s best action?
You Selected:
Ask what time this happened and note the color, amount, andodor of the fluid.
Correct response:
Ask what time this happened and note the color, amount, andodor of the fluid.
Question 13
When documenting the care of a client, the nurse is aware of the need to use abbreviations
conscientiously and safely. This includes
You Selected:
ensuring the abbreviations are understandable to clients whomay seek access to their health
records
Correct response:
limiting abbreviations to those approved for use by theinstitution
Question 14
During routine prenatal screening, a nurse tells a client that herblood sample will be used for alpha
fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?
You Selected:
"This screening indicates if your baby's lungs are mature."
Correct response:
"This test will screen for spina bifida, Down syndrome, orother genetic defects."