AND ANSWERS (VERIFIED REVISED EXAM) LATEST
2025/2026
The nurse observes that a male client has removed the covering from an ice park applied to his knee.
What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. - answer :Observe the appearance of the skin
under the ice pack (The first action taken by the nurse should be to assess the skin for any possible
thermal injury. If no injury to the skin has occurred, the nurse can take the other actions.)
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-
delivered medication to demonstrate correct use of the inhaler?
A) Immediately after exhalation.
B) During the inhalation.
C) At the end of three inhalations.
D) Immediately after inhalation - answer :B) During the inhalation
The client should be instructed to deliver the medication during the last part of inhalation (B). After the
medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and
breath held for several seconds to allow for distribution of the medication. The client should not deliver
the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C).
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as
rapidly as possible. Which intervention is most important for the nurse to implement?
,A) Obtain the pre-transfusion hemoglobin level.
B) Prime the tubing and prepare a blood pump set-up.
C) Monitor vital signs q15 minutes for the first hour.
D) Ensure the accuracy of the blood type match. - answer :D) Ensure the accuracy of the blood type
match
All interventions should be implemented prior to administering blood, but (D) has the highest priority.
Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order
to prevent a possible hemolytic reaction
On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription.
When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and
successfully revives the client. What legal issues could be brought against the nurse?
A) Assault.
B) Battery.
C) Malpractice.
D) False imprisonment. - answer :B) Battery
Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to
engage in harmful contact with another) or battery (unwanted touching). Performing any procedure
against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is
of questionable benefit to the client. (A, C, and D) are not examples against the client's request
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus
enteral feedings though a gastrostomy tube. What is the best client position for administration of the
bolus tube feedings?
A) Prone.
B) Fowler's.
C) Sims'.
,D) Supine. - answer :B) Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the
occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a
percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an
incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client.
In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in
(D) increases the risk of aspiration
An older client who is a resident in a long term care facility has been bedridden for a week. Which
finding should the nurse identify as a client risk factor for pressure ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower extremities.
C) Red flush over entire skin surface.
D) Rashes in the axillary, groin, and skin fold regions - answer :D) Rashes in the axillary, groin, and skin
fold regions
Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow
is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin
breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of
inflammation and tissue integrity
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family,
which includes several adult children and their children. What is the best plan to obtain consent for
surgery for this client?
A) Obtain an interpreter to explain the procedure to the client.
B) Encourage the client to make her own decision regarding surgery.
C) Ask the family members to provide an interpretation of the surgeon's explanation to the client.
D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. -
answer :D) Tell the surgeon that the son will decide after explanation of the proposed surgery is
provided
, Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the
son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive
information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's
family at this time. It is culturally insensitive to encourage the woman to go against her religious and
cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but
the son should be the primary decision-maker for his mother (C).
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a
desired outcome measure has been met?
A) Expresses concern about the meaning and importance of life
B) Remains angry at God for the continuation of the illness.
C) Accepts that punishment from God is not related to illness.
D) Refuses to participate in religious rituals that have no meaning. - answer :C) Accepts that punishment
from God is not related to illness
Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of
resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and
cultural/spiritual acceptance.
Immediate defibrillation
Explanation:
Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole
(cardiac arrest) when no identifiable R wave is present. - answer :You enter your client's room and find
him pulseless and unresponsive. What would be the treatment of choice for this client?
used to treat ventricular fibrillation and unstable ventricular tachycardia - answer :Amiodarone
used to treat symptomatic bradycardia - answer :atropine
Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin
that will cause the body to start to break down stored fat for energy.
Explanation: