WITH REVISED QUESTIONS AND CERTIFIFED ANSWERS |
GRADE A+ | 100 % GUARANTEED | (BRANDNEW)!!
UPDATED
Question: The charge nurse receives a change-of-shift report on several clients in labor.
Which client should be seen first?
A. First-stage labor with an oral temperature of 99.7° F (37.6° C)
B. First-stage labor whose contractions occur every 30 seconds
C. Second-stage labor with respirations of 26
D. Second-stage labor whose contractions last 60 seconds
Answer: B. First-stage labor whose contractions occur every 30 seconds
Rationale: Contractions should not be longer than 90 seconds or closer than 2 minutes
apart. Contractions every 30 seconds indicate hyperstimulation, which can compromise
fetal oxygenation. Mild temperature elevation and increased respirations are normal
during labor.
Question: A staff member is caring for a client with chickenpox. Which action requires
intervention?
A. Placing the client in a private room with negative air pressure
B. Placing a box of disposable face shields outside the client’s room
C. Placing an alcohol-based hand rub in the client’s room
D. Placing a surgical mask on the client during transport
Answer: B. Placing a box of disposable face shields outside the client’s room
Rationale: Chickenpox (varicella) is airborne. Disposable face shields are insufficient
protection; airborne precautions require N95 respirators or negative-pressure isolation.
Question: A client is experiencing bradycardia on ECG. Which actions are appropriate?
(Select all that apply)
A. Administer the prescribed beta blocker
B. Prepare for transcutaneous pacing
C. Instruct the client to perform the Valsalva maneuver
,D. Begin chest compressions
E. Assess the client for angina
Answer: B, E
Rationale: Beta blockers and Valsalva maneuvers would worsen bradycardia. Chest
compressions are for cardiac arrest. Transcutaneous pacing and assessment for angina are
appropriate interventions.
Question: Which intervention is appropriate for a client with moderate Alzheimer’s
disease?
A. Encourage reminiscing about happy memories
B. Confront inappropriate behaviors
C. Administer cholinesterase inhibitors to reverse AD
D. Have the client plan daily activities
Answer: A. Encourage reminiscing about happy memories
Rationale: Long-term memories are often retained in moderate AD. Confrontation is
ineffective, AD is irreversible, and expecting independent planning can cause frustration.
Question: What instruction should a nurse include when teaching a client to use crutches?
A. “Use your hands and arms to support your body weight.”
B. “Wear slippers when ambulating.”
C. “Maintain crutches 12 inches in front of your feet.”
D. “Adjust hand grips so elbows are fully extended.”
Answer: A. “Use your hands and arms to support your body weight.”
Rationale: Elbows should be slightly bent (30°), crutches should be 6 inches in front and 6
inches lateral, and slippers increase fall risk.
Question: A client with MS reports blurred vision. Which statement indicates correct
understanding?
A. “I will complete all household chores in the morning.”
B. “I have learned bladder massage techniques.”
C. “I will take a hot bath to relax.”
D. “Blurred vision will resolve after medications.”
Answer: D. “Blurred vision will resolve after medications.”
,Rationale: Optic neuritis in MS may resolve in 4–12 weeks, sometimes faster with steroids.
Hot baths can worsen MS symptoms.
Question: Which statement about positive-pressure ventilation indicates correct
understanding?
A. Avoid ROM exercises until weaned
B. Clients may develop stress ulcers and GI bleeding
C. Clients will be chemically paralyzed to improve oxygenation
D. Clients will experience diuresis and polyuria
Answer: B. Clients may develop stress ulcers and GI bleeding
Rationale: Mechanical ventilation can increase risk of stress ulcers due to stress response
and decreased perfusion.
Question: A charge nurse must transfer a client to another unit. Who is most appropriate
to transfer?
A. 28-year-old post-mastectomy with closed-wound drainage
B. 49-year-old with diabetes starting insulin
C. 56-year-old with hepatitis C, afebrile 24 hours
D. 70-year-old with a fractured tibia and external fixation
Answer: C. 56-year-old with hepatitis C, afebrile 24 hours
Rationale: Stable, afebrile clients without acute post-op needs are safest to transfer.
Question: A nurse must assess clients. Which client should be seen first?
A. Heart failure with productive cough and anxiety
B. Crohn’s disease with cramping and diarrhea
C. ITP with petechiae and heavy menses
D. COPD with exertional dyspnea
Answer: A. Heart failure with productive cough and anxiety
Rationale: Pink, frothy sputum may indicate pulmonary edema, a life-threatening
complication requiring immediate attention.
Question: Which task can be safely assigned to a UAP?
A. Assisting a client with atrial fibrillation to shower
B. Checking swallow ability post-TEE
, C. Observing dysphagia diet initiation
D. Transporting a client in respiratory distress
Answer: A. Assisting a client with atrial fibrillation to shower
Rationale: UAP can perform hygiene; assessment and unstable clients require a licensed
nurse.
Question: A 9-month-old client consumes 10 bottles of 2% milk daily. Why is follow-up
needed?
A. Normal for age
B. Risk for dehydration
C. Risk for iron deficiency
D. Encourages weight gain
Answer: C. Risk for iron deficiency
Rationale: Excess cow’s milk before 12 months can cause iron deficiency and inadequate
nutrition.
Question: Which is a violation of client privacy?
A. Discussing catheter size with UAP
B. Sharing BAL results with police
C. Assisting a client with call light
D. Allowing a nursing student to review the record
Answer: B. Sharing BAL results with police
Rationale: Protected health information should not be shared unless legally required.
Question: Which client requires immediate assessment after lung surgery?
A. Right pneumonectomy, high Fowler’s, lying on right side
B. COPD, using pursed-lip breathing, reports hemoptysis
C. Wedge resection, high Fowler’s
D. Heart failure with productive cough and restlessness
Answer: D. Heart failure with productive cough and restlessness
Rationale: Pulmonary edema indicated by pink, frothy sputum is life-threatening.
GRADE A+ | 100 % GUARANTEED | (BRANDNEW)!!
UPDATED
Question: The charge nurse receives a change-of-shift report on several clients in labor.
Which client should be seen first?
A. First-stage labor with an oral temperature of 99.7° F (37.6° C)
B. First-stage labor whose contractions occur every 30 seconds
C. Second-stage labor with respirations of 26
D. Second-stage labor whose contractions last 60 seconds
Answer: B. First-stage labor whose contractions occur every 30 seconds
Rationale: Contractions should not be longer than 90 seconds or closer than 2 minutes
apart. Contractions every 30 seconds indicate hyperstimulation, which can compromise
fetal oxygenation. Mild temperature elevation and increased respirations are normal
during labor.
Question: A staff member is caring for a client with chickenpox. Which action requires
intervention?
A. Placing the client in a private room with negative air pressure
B. Placing a box of disposable face shields outside the client’s room
C. Placing an alcohol-based hand rub in the client’s room
D. Placing a surgical mask on the client during transport
Answer: B. Placing a box of disposable face shields outside the client’s room
Rationale: Chickenpox (varicella) is airborne. Disposable face shields are insufficient
protection; airborne precautions require N95 respirators or negative-pressure isolation.
Question: A client is experiencing bradycardia on ECG. Which actions are appropriate?
(Select all that apply)
A. Administer the prescribed beta blocker
B. Prepare for transcutaneous pacing
C. Instruct the client to perform the Valsalva maneuver
,D. Begin chest compressions
E. Assess the client for angina
Answer: B, E
Rationale: Beta blockers and Valsalva maneuvers would worsen bradycardia. Chest
compressions are for cardiac arrest. Transcutaneous pacing and assessment for angina are
appropriate interventions.
Question: Which intervention is appropriate for a client with moderate Alzheimer’s
disease?
A. Encourage reminiscing about happy memories
B. Confront inappropriate behaviors
C. Administer cholinesterase inhibitors to reverse AD
D. Have the client plan daily activities
Answer: A. Encourage reminiscing about happy memories
Rationale: Long-term memories are often retained in moderate AD. Confrontation is
ineffective, AD is irreversible, and expecting independent planning can cause frustration.
Question: What instruction should a nurse include when teaching a client to use crutches?
A. “Use your hands and arms to support your body weight.”
B. “Wear slippers when ambulating.”
C. “Maintain crutches 12 inches in front of your feet.”
D. “Adjust hand grips so elbows are fully extended.”
Answer: A. “Use your hands and arms to support your body weight.”
Rationale: Elbows should be slightly bent (30°), crutches should be 6 inches in front and 6
inches lateral, and slippers increase fall risk.
Question: A client with MS reports blurred vision. Which statement indicates correct
understanding?
A. “I will complete all household chores in the morning.”
B. “I have learned bladder massage techniques.”
C. “I will take a hot bath to relax.”
D. “Blurred vision will resolve after medications.”
Answer: D. “Blurred vision will resolve after medications.”
,Rationale: Optic neuritis in MS may resolve in 4–12 weeks, sometimes faster with steroids.
Hot baths can worsen MS symptoms.
Question: Which statement about positive-pressure ventilation indicates correct
understanding?
A. Avoid ROM exercises until weaned
B. Clients may develop stress ulcers and GI bleeding
C. Clients will be chemically paralyzed to improve oxygenation
D. Clients will experience diuresis and polyuria
Answer: B. Clients may develop stress ulcers and GI bleeding
Rationale: Mechanical ventilation can increase risk of stress ulcers due to stress response
and decreased perfusion.
Question: A charge nurse must transfer a client to another unit. Who is most appropriate
to transfer?
A. 28-year-old post-mastectomy with closed-wound drainage
B. 49-year-old with diabetes starting insulin
C. 56-year-old with hepatitis C, afebrile 24 hours
D. 70-year-old with a fractured tibia and external fixation
Answer: C. 56-year-old with hepatitis C, afebrile 24 hours
Rationale: Stable, afebrile clients without acute post-op needs are safest to transfer.
Question: A nurse must assess clients. Which client should be seen first?
A. Heart failure with productive cough and anxiety
B. Crohn’s disease with cramping and diarrhea
C. ITP with petechiae and heavy menses
D. COPD with exertional dyspnea
Answer: A. Heart failure with productive cough and anxiety
Rationale: Pink, frothy sputum may indicate pulmonary edema, a life-threatening
complication requiring immediate attention.
Question: Which task can be safely assigned to a UAP?
A. Assisting a client with atrial fibrillation to shower
B. Checking swallow ability post-TEE
, C. Observing dysphagia diet initiation
D. Transporting a client in respiratory distress
Answer: A. Assisting a client with atrial fibrillation to shower
Rationale: UAP can perform hygiene; assessment and unstable clients require a licensed
nurse.
Question: A 9-month-old client consumes 10 bottles of 2% milk daily. Why is follow-up
needed?
A. Normal for age
B. Risk for dehydration
C. Risk for iron deficiency
D. Encourages weight gain
Answer: C. Risk for iron deficiency
Rationale: Excess cow’s milk before 12 months can cause iron deficiency and inadequate
nutrition.
Question: Which is a violation of client privacy?
A. Discussing catheter size with UAP
B. Sharing BAL results with police
C. Assisting a client with call light
D. Allowing a nursing student to review the record
Answer: B. Sharing BAL results with police
Rationale: Protected health information should not be shared unless legally required.
Question: Which client requires immediate assessment after lung surgery?
A. Right pneumonectomy, high Fowler’s, lying on right side
B. COPD, using pursed-lip breathing, reports hemoptysis
C. Wedge resection, high Fowler’s
D. Heart failure with productive cough and restlessness
Answer: D. Heart failure with productive cough and restlessness
Rationale: Pulmonary edema indicated by pink, frothy sputum is life-threatening.
