EXAM ACTUAL EXAM 180 QUESTIONS AND CORRECT DETAILED ANSWERS -
VERIFIED ANSWERS| ALREADY GRADED A+ NEW, GUARANTEED PASS.
A nurse working at a crisis hotline call center receives a call from a client who states, " I cannot take it.
My life is over. Which of the following is the priority response by the nurse?
ANSWER –
Are you thinking of harming yourself
A nurse is collecting data from a 3-month-old infant who is 6 hr. postoperative following a cleft palate
repair. Which of the following pain rating tools should the nurses use?
a. FACES Scale
b. FLACC scale
c. Color tool
d. Numeric scale
A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is
a subjective indication that the client needs PRN pain medication?
A. The client's heart rate is 110/min
B. The client is guarding their abdominal incision
C. The client exhibits facial grimacing.
D. The client reports pain.
A nurse is assisting with the admission of a client who has mononucleosis. Which of the following
isolation precaution should the nurse initiate?
a) Airborne
b) Droplet
c) Contact
d) Protective environment
A nurse is caring for a client who has a cast on their left lower leg. Which of the following actions should
the nurse take?
A. Massage areas around the edge of the client's cast with lotion
B. Avoid elevating the extremity when the client is resting in bed
C. Give the client a dull object to scratch the skin under the cast
D. Tell the client to expect numbness in their toes.
,A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder.
Which of the following instructions should the nurse include?
a) Call EMS if a seizure lasts 5 mins or more.
b) Restrain the child at the onset of the seizure
c) Offer the child a bubble bath every evening
d) Place the child in a prone position during seizure
A nurse is caring for a client who was recently admitted to an inpatient mental health unit. The nurse tells
the nurse that he is not coming out of his room anymore because other clients on the unit make fun of
him. Which of the following responses by the nurse is appropriate?
A. "I think you should just ignore the others."
B. "You feel upset by the responses of others."
C. "Let's keep the focus of our discussion on your needs."
D. "Everything will get better once you get to know everyone."
A nurse is assisting with the care of an adolescent who is scheduled for surgery. Which of the following
actions should the nurse plan the take?
A. Provide a tour of the perioperative area prior to surgery.
B. Explain that anesthesia is a special type of sleep.
C. Wait until after surgery to explain the importance of coughing and deep breathing.
D. Keep medical equipment out of the client's sight.
A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings
should the nurse expect?
a) Decrease blood pressure
b) Pale yellow urine
c) Periorbital edema
d) Increase urination
A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of the
following techniques should the nurse plan to use to assist with time management?
a) Delegate complicated tasks to an RN
b) Document all client care at the end of the shift
c) Perform quick tasks before time-consuming tasks
d) Try to complete a task before moving on to the next
,A nurse is preparing a client's insulin regimen. Which of the following insulins can be mixed? (Select all
that apply)
A. Insulin apart
B. Regular insulin
C. Insulin glargine
D. Insulin detemir
E. Insulin lispro
A nurse is collecting data from an 18-month-old toddler at a well-child visit. Which of the following
findings should the nurse report to the provider?
a) The toddler can remove her own socks
b) The toddler has a security blanket
c) The toddler can say four words
d) The toddler throws a ball without falling
A nurse is caring for several clients who are receiving well-child check-ups. The nurse should identify
that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for which of the following
clients?
a) A 2-month-old infant
b) A 4-month-old infant
c) A 6-month-old infant
d) A 15-month-old toddler
A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which of the
following responses should the nurse identify as the speech alteration of echolalia?
a) "I am lovistrated"
b) "Super, Trooper, and duper"
c) "How are you?"
d) "Pink spots in Africa"
A nurse is caring for an adolescent who has an allergy to penicillin. Which of the following prescriptions
should the nurse clarify with the provider?
a) ampicillin
b) Vibramycin
c) Cefazolin
d) Gentamicin
, A nurse is reinforcing discharge teaching with a client who is postoperative following laser surgery for
open-angel glaucoma. Which of the following statements by the client indicates an understanding of the
instructions?
A. "I will take a stool softener to prevent constipation."
B. "I will ask to work the night shift, so I will not be driving in bright sunlight."
C. "I will need to use my eye drops for 1 year."
D. "I will need to follow a low-protein diet."
A nurse is caring for a client who is recovering from electroconvulsive therapy. Which of the following
findings should the nurse identify as an adverse effect of the treatment?
a) Cough
b) Confusion
c) Hoarseness
d) Tingling of the scalp
A nurse is reinforcing teaching about confidentiality with a client. Which of the following statements
should the nurse include in the teaching?
A. "Your nurse will provide information about the risks and benefits of surgical procedures."
B. "Only health care staff providing care will see your medical record."
C. "The provider must grant you access to your personal health information."
D. "You have to authorize our providers to prescribe treatments for your condition."
A nurse is reinforcing teaching with a newly licensed nurse about HIPAA Privacy Rule. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
a) "The actual medical record belongs to the client"
b) "A client's medical record information remains confidential, even during an emergency"
c) "If the client dies, their family receives their medical record"
d) "A client has the right to view their medical record"