B, C ACTUAL EXAM LATEST 2025 ACTUAL EXAM
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GRADED A
The nurse cares for a client after an involuntary admission to a mental health facility due to threatening to harm self. The
family asks the nurse if they can take the client home. Which response by the nurse is MOST appropriate?
a. I will speak to the health care provider about your request.
b. The client is lucky to have a loving family like you.
c. The courts determine how long the client is hospitalized.
d. Why do you want to take the client home?
c. The courts determine how long the client is hospitalized.
The nurse cares for the adolescent diagnosed with Hodgkin's lymphoma. The adolescent receives nitrogen mustard,
vincristine, procarbazine and prednisone. Which adverse effect of the drugs requires early preparation of the adolescent?
a. Constipation
b. Retarded growth in height
c. Alopecia
d. Nausea
c. Alopecia
The home care nurse instructs the client receiving long-term prednisone therapy. Which information should the nurse
include?
a. There is an increased risk for developing infections.
b. There is a resistance to developing infections.
c. The client should follow a high-protein diet.
d. There are changes in fat distribution over several areas of the body.
d. There are changes in fat distribution over several areas of the body
The nurse witnesses a co-worker put one of two narcotic tablets in the co-workers purse twice during the shift. Which action
should the nurse take?
,a. Confront the co-worker
b. Consult other staff about observation
c. Inform the nursing supervisor
d. Write an incident report
c. Inform the nursing supervisor
The nurse cares for the client with a pacemaker. When monitoring pacemaker functions, which should the nurse assess
FIRST?
a. Incision site
b. Apical pulse
c. Blood pressure
d. Electrocardiogram (ECG)
d. Electrocardiogram (ECG)
The adolescent diagnosed with acute mania is started on lithium. Which behavior indicates to the nurse the medication is
effective?
a. Decreased euphoria and slower rate of speech noted.
b. Increased interest in sexual activity.
c. Improved appetite and stable weight.
d. Increased social interaction noted during meal times.
a. Decreased euphoria and slower rate of speech noted.
The nurse suspects that the client with severe uterine bleeding is in the early stages of shock. Which is the PRIORITY nursing
action?
a. Apply super absorbent perineal pads.
b. Establish intravenous access.
c. Administer oxygen per nasal cannula.
d. Place the client in Trendelenburg position.
c. Administer oxygen per nasal cannula.
,When providing respiratory care for the client with a tracheostomy, it is MOST important for the nurse to take which action?
a. Keep the trach cuff inflated during suctioning.
b. Apply suction as the catheter is being inserted.
c. Instill acetylcysteine just prior to suctioning.
d. Preoxygenate the client prior to suctioning.
d. Preoxygenate the client prior to suctioning.
The nurse provides care to a client diagnosed with cirrhosis. Which is the BEST explanation for the development of edema?
a. Decreased concentration of plasma albumin.
b. Decreased production of aldosterone causing sodium and water retention.
c. Shunting of the blood from the portal vessels into the lower pressure vessels.
d. Inadequate formation, use and storage of vitamin K.
a. Decreased concentration of plasma albumin.
With cirrhosis there is malnutrition, with malnutrition there is decreased albumin, with decreased albumin there is edema.
Nurses working in hospital environments should follow which guideline related to effective hand washing?
a. Use a petroleum-based lotion for prevention of dryness.
b. Have the water temperature as hot as tolerated.
c. Clean under artificial nails prior to starting shift.
d. Wash for at least fifteen seconds covering all surfaces.
d. Wash for at least fifteen seconds covering all surfaces
The nurse cares for the primigravida during the transition phase of labor. Which is MOST important for the nurse to include
in the client's plan of care?
a. Provide feedback to reduce client's anxiety.
b. Assess client's emotional reaction to impending parenthood.
c. Catheterize client is unable to void for 2 hours.
d. Provide comfort measures including position changes.
d. Provide comfort measures including position changes.
, The nurse cares for the client diagnosed with a hearing impairment. Which is a PRIORITY action for the nurse to take?
a. Talk with a raised voice.
b. Utilize more hand gestures.
c. Speak at a slightly slower pace.
d. Use more facial expressions.
c. Speak at a slightly slower pace.
The nurse cares for the newborn with a port wine stain covering the face and half the body. The nurse notes that the mother
refuses to look at the newborn. Which response by the nurse is MOST appropriate?
a. Allow the mother to recover from the fatigue of delivery and then bring the newborn to her.
b. Empathetically the mother not to blame herself for the newborn's appearance.
c. Talk to the family about the situation and encourage the family to comfort the other.
d. Reinforce the health care pr
d. Reinforce the health care provider's explanation of the defect and allow time for the mother to discuss her fears.
The nurse reviews a diet containing broiled catfish, baked green beans, a roll, a brownie, and tea. The nurse identifies this
diet is most appropriate for which condition?
a. Celiac disease.
b. Type 1 diabetes.
c. Acute pancreatitis.
d. Crohn's disease.
d. Crohn's disease.
The nurse cares for a toddler diagnosed with croup. The nurse notes the toddler's respiratory and heart rates have increased
significantly. Sub sternal and intercostal
retractions are pronounced, and the child is restless. Which action should the nurse take FIRST?
a. Suction the child's airway.
b. Contact the health care provider.