EXAM ANSWERS (DETAILED ANSWERS)
2024 - DISTINCTION GUARANTEED
24-hr Urine Collection - ANS-Client saves all urine since last flush at 7:00 a.m.
Thrombophlebitis - ANS-Indicated by calf swelling in a client on bed rest
HIPAA Violation - ANS-Asking a nurse from another unit to assist with documentation
Antiembolic Stockings - ANS-Remove at least once per shift for a client on bed rest
IV Fluid Assessment - ANS-Monitor adverse effects by auscultating lung sounds
Readiness to Learn - ANS-Client's best concentration time indicates readiness
Romberg's Test - ANS-Client stands with arms at side and feet together for balance assessment
Extra Time Strategy - ANS-Allow more time for responses from an older adult with type 2 diabetes
Osteoporosis Prevention - ANS-Recommend brisk walking for an older adult at risk
Immobility Complication - ANS-Erythema on pressure points requires further intervention
Oral Medication Administration - ANS-Gently shake oral medication before administration
Emergency Response - ANS-Check for injuries first when finding a client on the floor
Anger Management - ANS-Reassure client expressing anger over diagnosis as a normal response
Colon Cancer Screening - ANS-Recommend fecal occult blood test annually for average risk clients
, Medication Documentation - ANS-Use complete name for medication magnesium sulfate
Tuberculosis Precaution - ANS-Isolate client in negative-pressure room, wear gloves, use sanitizer
C. difficile Infection - ANS-Instruct family to wear gown and gloves when visiting infected clients
Latex Allergy Precaution - ANS-Wrap monitoring cords with stockinette for a client with latex allergy
Insomnia Management - ANS-Recommend progressive relaxation techniques for falling asleep
Insulin Mixing Order - ANS-Air into NPH, air into Regular, draw up Regular, draw up NPH
RN Scope of Practice - ANS-Initiate enteral feeding through a gastrostomy tube within RN scope
NG Tube Insertion - ANS-Have client sip water to aid NG tube insertion into esophagus
Fall Risk Assessment - ANS-Assess pupil clarity, visual fields, and visual acuity for safety needs
Cane Use Evaluation - ANS-Correct use involves holding the cane on the stronger side of the body
Peripheral Vascular Assessment - ANS-Narrowed arterial lumen indicated by sound when placing
stethoscope on neck
Varicella Precaution - ANS-Initiate airborne precautions for a client with varicella
Enteral Feeding Tube Care - ANS-Flush tube with 15 mL of sterile water for a client with an enteral
feeding tube
Wound Irrigation Procedure - ANS-Cleanse wound from center outward for a client with a wound
irrigation prescription
Incident Report Completion - ANS-Complete report for a client receiving extra IV fluid via infusion pump
Infiltration Identification - ANS-Identify infiltration by skin blanching at the IV site
Change-of-Shift Report Tool - ANS-Use SBAR for communicating continuity of care during shift change
Abdominal Wound Precaution - ANS-Initiate contact precautions for a client with purulent drainage from
an abdominal wound
Breathing Difficulty Care - ANS-Assist client with nasal cannula delivering oxygen while lying in bed
Upright Position - ANS-Initial intervention for a client with difficulty breathing
Potassium Level - ANS-Finding to report if it's 5.4 meq/L in a client's fluid and electrolyte status
Close Proximity - ANS-Nurse's action to prevent self-injury when lifting a bedside cabinet