Answers| LATEST, 2025/2026|With Correct Answers &
Rationale
1. A nurse in a long-term care facility is assisting with an inservice for newly hired
assistive personnel about legal issues within the facility. Which of the following should
the nurse include as an example of assault?
ANS: Informing a client the nurse is going to administer an injection even though the client
refuses
2. A nurse is collecting data from those who are in severe pain. Which of The following
questions should the nurse ask first?
ANS: "Where is your pain located?"
3. A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation.
For which of the following results should the nurse notify the provider?
ANS: Platelet count 95,000 mm3
4. A nurse is performing a dressing change for a client who had abdominal surgery 5
days ago. The nurse notes organs protruding from the incision. Which ofIthe following
actions should the nurse take?
ANS: Cover the exposed area with sterile, saline-soaked Dressings.
5. A nurse is speaking with the adult daughter of a client who has Alzheimer's disease.
The daughter states, "I love my dad, but caring for him is wearing me out." Which of the
following responses should the nurse make?
ANS: "Let's discuss how caring for your father is affecting your health.
6. A nurse is contributing to the plan of care for a client who has a chest tube connected
to a closed drainage system. Which ofIthe following actions should the nurse include in
, the FLplan FLof FLcare?
ANS: FLMaintain FLthe FLdrainage FLsystem FLbelow FLthe FLlevel FLof FLthe FLclient's FLchest.
7. A FLnurse FLin FLan FLacute FLmental FLhealth FLfacility FLis FLcaring FLfor FLa FLclient FLwho
FLhas FLborderline FLpersonality FLdisorder FLand FLreports. FL"I FLam FLgoing FLto FLkill FLmy
FLgirlfriend FLwhen FLI FLget FLout FLof FLhere." FLWhich FLofIthe FLfollowing FLactions FLshould
FLthe FLnurse FLtake?
ANS: FLNotify FLthe FLclient's FLcare FLteam FLof FLthe FLthreats FLagainst FLthe FLPartner
8. A FLnurse FLis FLadmitting FLa FLclient FLwho FLis FLat FLhigh FLrisk FLfor FLsuicide.Which
FLofIthe FLfollowing FLactions FLis FLthe FLnurse's FLpriority?
ANS: FLSearch FLthe FLclient's FLpersonal FLbelongings
9. A FLnurse FLis FLcaring FLfor FLa FLclient FLwho FLis FL1 FLday FLpostoperative FLand FLis
FLunable FLto FLambulate. FLWhich FLof FLthe FLfollowing FLactions FLshould FLthe FLnurse
FLtake FLto FLpromote FLthe FLclient's FLvenous FLreturn?
ANS: FLMaintain FLthe FLsequential FLcompression FLdevice.
10. A FLnurse FLin FLan FLacute FLcare FLunit FLis FLcollecting FLdata FLfrom FLa FLschool FLage
FLChild FLwho FLhas FLcystic FLfibrosis. FLWhich FLofIthe FLfollowing FLfindings FLis FLthe
FLpriority FLfor FLthe FLnurse?
ANS: FLReports FLlack FLof FLappetite
11. A FLnurse FLworking FLin FLa FLprovider's FLfollowing FLreceives FLa FLphone FLcall FLfrom
FLthe FLparent FLof FLa FLschool FLage FLchild FLwho FLhas FLvaricella. FLThe FLparent FLasked
FLthe FLnurse FLwhen FLthe FLchild FLcould FLreturn FLto FLschool. FLWhich FLof FLthe
FLfollowing FLresponses FLshould FLthe FLnurse FLmake?
ANS: FL"When FLthe FLlesions FLhave FLscabbed FLover."
12. A FLnurse FLin FLa FLpediatric FLclinic FLis FLcollecting FLthe FLdata FLfrom FLa FLschool FLage
FLchild FLwhose FLinjuries FLare FLinconsistent FLwith FLthe FLparent's FLstated FLcause. FLWhich
FLofIthe FLfollowing FLactions FLshould FLthe FLnurse FLtake?
ANS: FLReport FLthe FLsuspected FLabuse FLto FLan FLappropriate FLagency.
13. A FLnurse FLis FLcollecting FLdata FLfrom FLa FLmiddle FLadult FLfemale FLclient FLwho
, FLis FLtaking FLmelatonin.Which FLofIthe FLfollowing FLresponses FLto FLthe FLmed
FLshould FLthe FLnurse FLexpect? FLANS: FLImproved FLsleep
14. A FLnurse FLon FLa FLpediatric FLunit FLis FLcollecting FLdata FLfrom FLfour FLnewly FLadmitted
FLclients. FLWhich FLofIthe FLfollowing FLclients FLshould FLthe FLnurse FLidentify FLas FLbeing
FLat FLrisk FLfor FLurinary FLretention?
ANS: FLA FLschool FLage FLchild FLwho FLhas FLallergic FLrhinitis FLand FLis FLtaking FLDiphenhydramine.
15. A FLnurse FLis FLpreparing FLto FLadminister FLa FLpurified FLprotein FLderivative(PPD) FLto FLa
FLclient FLwho FLha FLs FLsuspected FLTB. FLWhich FLofIthe FLfollowing FLactions FLshould FLthe
FLnurse FLplan FLto FLtake?
ANS: FLEnsure FLthe FLinjection FLproduces FLa FLwheal FLon FLthe FLskin
16. A FLclient FLwho FLis FLdiagnosed FLwith FLParkinson's FLdisease FLverbalizes FLfrustration
FLdue FLto FLincreased FLdifficulty FLwith FLambulation. FLWhich FLof FLthe FLfollowing
FLresponses FLshould FLthe FLnurse
take?
ANS: FLPerform FLactive FLROM FLwith FLyour FLarms FLand FLlegs FLtwo FLtimes FLa FLday
17. A FLnurse FLis FLcollecting FLdata FLfrom FLa FLclient FLwho FLhas FLmultiple FLfractures
FLfollowing FLa FLmotor-vehicle FLcrash. FLFor FLwhich FLof FLthe FLfollowing FLclient
FLstatements FLshould FLthe FLnurse FLrecommend FLa FLreferral FLto FLan FLoccupational
FLtherapist?
i FLam FLso FLfrustrated FLi FLcannot FLeven FLopen FLmy FLmilk FLcarton FLfor FLbreakfast
18. A FLnurse FLis FLcaring FLfor FLa FLclient FLwho FLis FL4 FLhr FLpostoperative FLfollowing FLa FLtotal
FLthyroidectomy FLWhich FLof FLthe FLfollowing FLmanifestations FLshould FLthe FLnurse
FLreport FLto FLthe FLprovider FLas FLindicating FLpossible FLhypocalcemia?
ANS: FLTingling FLof FLfingers
19. A FLnurse FLis FLcaring FLfor FLa FLclient FLwho FLhas FLa FLPenrose FLdrain. FLTo FLensure
, FLproper FLplacement FLand FLfunctioning FLof FLthe FLdrain, FLwhich FLof FLthe FL following
FLshould FLthe FLnurse FLexpect FLto FLobserve?
ANS: FLThe FLsafety FLpin FLis FLpresent FLat FLthe FLdistal FLend FLof FLthe FLdrain.
20. A FLcommunity FLhealth FLnurse FLis FLhelping FLto FLreinforce FLteaching FLabout
FLhepatitis FLA FLwith FLa FLgroup FLof FLemployees FLat FLa FLchildcare FLfacility. FLWhich FLof FLthe
FLfollowing FLcharacteristics FLshould FLthe FLnurse FLidentify FLas FLan FLexternal FLfactor
FLthat FLcan FLimpede FLlearning FLfor FLthe FLparticipants?
ANS: FLPoor FLlighting FLin FLthe FLlearning FLsetting
21. A FLnurse FLis FLobserving FLa FLnewly FLlicensed FLnurse FLwho FLis FLproviding
FLtracheostomy FLcare FLfor FLa FLclient. FLThe FLnurse FLidentifies FLproper FLperformance FLof
FLthe FLprocedure FLwhen FLthe FLnewly FLlicensed FLnurse FLselects FLwhich FLof FLthe
FLfollowing FLsolutions FLto FLclean FLthe FLinner FLcannula?
ANS: FLHydrogen FLperoxide
22. A FLnurse FLis FLcaring FLfor FLa FLclient FLwho FLhas FLright FLsided FLheart FLfailure. FLThe
FLclient's FLpartner FLexpresses FLconcern FLthat FLthe FLclient FLwill FLdie. FLWhich FLofIthe
FLfollowing FLresponses FLshould FLthe FLnurse FLmake?
ANS: FL"It FLis FLdifficult FLto FLsee FLsomeone FLso FLsick. FLWhat FLhave FLyou FLbeen FLtold FLabout FLyour
FLpartner's FLprognosis?"
23. A FLnurse FLis FLreinforcing FLdischarge FLinstructions FLwith FLthe FLparent FLof FLan FLinfant
FLwho FLhas