And Verified Answers 2025/2026 Latest
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A client is comatose upon arrival to the emergency department after falling
a roof. The client flexes with painful stimuli, and the nurse determines the
client's Glasgow Coma Scale (GCS) is 6. Which intervention should the
nurse prepare to implement to maintain the client's airway? - ANS>> A
nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50 ml/hr. To
prepare enough of the solution for eight hours, how many ml of full strength
feeding will the nurse need? - ANS>> Answer: 200
25 ml x 8hrs = 200
The alarm of a client's pulse oximeter sounds and the nurse notes that the
oxygen saturation rate is indicated at 85%. What action should the nurse
take first? - ANS>> Check the probe position
A retiree with depression complains of feeling "lonely and having no
purpose" in life.Based on Erikson's developmental theory, which questions
suggest that the nurse understands the client's most important emotional
need? - ANS>> "What about your life makes you proud?"
A client is known to have an irregular respiratory rate with periods of apnea
lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles
in a 30-second interval followed by an apneic period. What intervention
should the nurse implement? - ANS>> Reassess the respiratory rate,
counting for one full minute
,Following a precipitous labor, a client has a continuous trickling of bright
red blood from her vagina. Her uterus is firm and her vital signs are within
normal limits. The
nurse determines that the client's symptoms may indicate which condition?
- ANS>> A cervical laceration
In preparing assignments for the shift, which client is best for the charge
nurse to assign to a practical nurse? - ANS>> An elderly client with
Alzheimer's disease complicated by dysphagia
The healthcare provider prescribes oxygen per nasal cannula at 2 L/min.
Which action has the highest priority when the nurse implements this
prescription? - ANS>> Set the flow meter
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of
an immobile client. What documentation of this finding is best for the nurse
to enter into the client's record? - ANS>> Stage 1 pressure ulcer on sacrum
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for
an injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action
should the nurse-manager who is supervising this nurse take first? -
ANS>> C. Instruct the nurse to select another injection site
10. After diagnosis and initial treatment of a 3-year-old child with cystic
fibrosis, the nurse provides home care instructions to the mother. Which
statement by the child's mother indicates that she understands home care
treatment to promote pulmonary function? - ANS>> "Chest physiotherapy
should be performed at least twice a day"
The nurse is preparing a community education program on osteoporosis.
Which instruction is helpful in preventing bone loss and promoting bone
formation? - ANS>> Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child
with Type 1 diabetes mellitus. The parents correctly understands signs of
hypoglycemia if they include which symptom? - ANS>> Sweating
When assessing a 7-year-old girl, the nurse notes that she has multiple
bruises on her back and upper arms. The child's aunt tells the nurse that
, the child's parents abuse drugs and alcohol. What intervention is most
essential for the nurse to implement? - ANS>> Report assessment findings
to the proper legal authorities
15. A 14-year-old male client arrives at the emergency room in status
epilepticus. He was diagnosed with a seizure disorder in childhood. What is
the most likely cause of his present condition? - ANS>> Acute withdrawal
from anticonvulsant medication
A Chinese-American client who just delivered a baby states that she will
not be able to take the prescribed sitz baths to help heal her episiotomy
incision because this will cause an unhealthy balance of cold and hot
forces. When planning nursing care, what nursing diagnosis has the
highest priority? - ANS>> Impaired tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102
F. In planning care for this child, which nursing diagnosis has the highest
priority? - ANS>> High risk for fluid volume deficit related to temperature
elevation
During the first trimester of pregnancy, a client who was treated for genital
herpes with acyclovir (Zovirax) prior to this pregnancy tells the nurse that
she is experiencing an episode of genital herpes. Which nursing
intervention has the highest priority? - ANS>> Determine if the client has
taken acyclovir (Zovirax) for this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new
prescription for paroxetine (Paxil). The client reports current use of the
MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to implement?
- ANS>> Notify the healthcare provider that the client is currently taking
Marplan
While performing a skin inspection on a newborn, the nurse finds a small
dimple and a dark tuft of hair in the lumbosacral area of the infant's back.
What is the most likely indication of this finding? - ANS>> External
manifestation of a spinal abnormality