COMPLETE SOLUTION THAT COVERS 2025/2026 BEST EXAM RATED
A+ FOR SUCCESS
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12
days. Which assessment finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating. - CORRECT ANSWERS Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to
increase the risk of suicidal thinking in adolescents and young adults with major depressive disorder.
B, C and D are side effects
A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear
results are negative. What information should the nurse include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed. - CORRECT ANSWERS Further
evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated
carefully
A client who recently underwent a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan?
a. Explain how to use communication tools.
,b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site. - CORRECT ANSWERS Teach tracheal suctioning
techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir
bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths /
minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data - CORRECT ANSWERS Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory
rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client
alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes. - CORRECT ANSWERS Respiratory apnea of 30
seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that should be assessed
first.
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action
should the nurse take first?
,a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level - CORRECT ANSWERS Check the client for lacerations or fractures
Rationale: fAfter fthe fclient ffalls, fthe fnurse fshould fimmediately fassess ffor fthe fpossibility fof
finjuries fand fprovide ffirst faid fas fneeded
Following fdischarge fteaching, fa fmale fclient fwith fduodenal fulcer ftells fthe fnurse fthe fhe fwill fdrink
fplenty fof fdairy fproducts, fsuch fas fmilk, fto fhelp fcoat fand fprotect fhis fulcer. fWhat fis fthe fbest
ffollow-up faction fby fthe fnurse?
a. fRemind fthe fclient fthat fit fis falso fimportant fto fswitch fto fdecaffeinated fcoffee fand ftea.
b. fSuggest fthat fthe fclient falso fplan fto feat ffrequent fsmall fmeals fto freduce fdiscomfort
c. fReview fwith fthe fclient fthe fneed fto favoid ffoods fthat fare frich fin fmilk fand fcream.
d. fReinforce fthis fteaching fby fasking fthe fclient fto flist fa fdairy ffood fthat fhe fmight fselect. f- f
fCORRECT fANSWERS f fReview fwith fthe fclient fthe fneed fto favoid ffoods fthat fare frich fin fmilk fand
fcream
Rationale: fDiets frich fin fmilk fand fcream fstimulate fgastric facid fsecretion fand fshould fbe favoided.
A fmale fclient fwith fhypertension, fwho freceived fnew fantihypertensive fprescriptions fat fhis flast
fvisit freturns fto fthe fclinic ftwo fweeks flater fto fevaluate fhis fblood fpressure f(BP). fHis fBP fis
f158/106 fand fhe fadmits fthat fhe fhas fnot fbeen ftaking fthe fprescribed fmedication fbecause fthe
fdrugs fmake fhim f"feel fbad". fIn fexplaining fthe fneed ffor fhypertension fcontrol, fthe fnurse fshould
fstress fthat fan felevated fBP fplaces fthe fclient fat frisk ffor fwhich fpathophysiological fcondition?
a. fBlindness fsecondary fto fcataracts
b. fAcute fkidney finjury fdue fto fglomerular fdamage
c. fStroke fsecondary fto fhemorrhage
d. fHeart fblock fdue fto fmyocardial fdamage f- f fCORRECT fANSWERS f fStroke fsecondary fto
fhemorrhage
Rationale: fStroke frelated fto fcerebral fhemorrhage fis fmajor frisk ffor funcontrolled fhypertension.
, The fnurse fobserves fan funlicensed fassistive fpersonnel f(UAP) fpositioning fa fnewly fadmitted fclient
fwho fhas fa fseizure fdisorder. fThe fclient fis fsupine fand fthe fUAP fis fplacing fsoft fpillows falong fthe
fside frails. fWhat faction fshould fthe fnurse fimplement?
a. fEnsure fthat fthe fUAP fhas fplaced fthe fpillows feffectively fto fprotect fthe fclient.
b. fInstruct fthe fUAP fto fobtain fsoft fblankets fto fsecure fto fthe fside frails finstead fof fpillows.
c. fAssume fresponsibility ffor fplacing fthe fpillows fwhile fthe fUAP fcompletes fanother ftask.
d. fAsk fthe fUAP fto fuse fsome fof fthe fpillows fto fprop fthe fclient fin fa fside flying fposition. f- f
fCORRECT fANSWERS f fInstruct fthe fUAP fto fobtain fsoft fblankets fto fsecure fto fthe fside frails finstead
fof fpillows
Rationale: fThe fnurse fshould finstruct fthe fUAP fto fpad fthe fside frails fwith fsoft fblankest fbecause
fthe fuse fof fpillows fcould fresult fin fsuffocation fand fwould fneed fto fbe fremoved fat fthe fonset fof
fthe fseizure. fThe fnurse fcan fdelegate fpaddling fthe fside frails fto fthe fUAP
At f0600 fwhile fadmitting fa fwoman ffor fa fschedule frepeat fcesarean fsection f(C-Section), fthe fclient
ftells fthe fnurse fthat fshe fdrank fa fcup fa fcoffee fat f0400 fbecause fshe fwanted fto favoid fgetting fa
fheadache. fWhich faction fshould fthe fnurse ftake ffirst?
a. fEnsure fpreoperative flab fresults fare favailable
b. fStart fprescribed fIV fwith flactated fRinger's
c. fInform fthe fanesthesia fcare fprovider
d. fContact fthe fclient's fobstetrician. f- f fCORRECT fANSWERS f fInform fthe fanesthesia fcare fprovider
Rationale: fSurgical fpreoperative finstruction fincludes fNPO fafter fmidnight fthe fday fof fsurgery fto
fdecrease fthe frisk fof faspiration fshould fvomiting foccur fduring fanesthesia. fWhile fit fis fpossible fthe
fC-section fwill fbe fdone fon fschedule for frescheduled ffor flater fin fthe fday, fthe fanesthesia fprovider
fshould fbe fnotified ffirst.
After fplacing fa fstethoscope fas fseen fin fthe fpicture, fthe fnurse fauscultates fS1 fand fS2 fheart
fsounds. fTo fdetermine fif fan fS3 fheart fsound fis fpresent, fwhat faction fshould fthe fnurse ftake ffirst
a. fSide fthe fstethoscope facross fthe fsternum.
b. fMove fthe fstethoscope fto fthe fmitral fsite