Questions 2026 Exam All
Answers and Illustrations Given
When turning an immobile bedridden client without assistance, which
action by the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly. - 🧠 ANSWER ✔✔B
,Rationale: Because the nurse can only stand on one side of the bed, bed
rails should be up on the opposite side to ensure that the client does not fall
out of bed. Option A can cause client injury to the skin or joint. Options C
and D are useful techniques while turning a client but have less priority in
terms of safety than use of the bed rails.
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What intervention
has the highest priority in decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns - 🧠 ANSWER ✔✔B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination to all clients. Option A
reverses the hypovolemia that initially accompanies burn trauma but is not
related to decreasing the proliferation of infective organisms. Options C and
D are recommended by various burn centers as possible ways to reduce
the chance of infection. Option B is a proven technique to prevent infection.
,The nurse is aware that malnutrition is a common problem among clients
served by a community health clinic for the homeless. Which laboratory
value is the most reliable indicator of chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level - 🧠 ANSWER ✔✔A
Rationale: Long-term protein deficiency is required to cause significantly
lowered serum albumin levels. Albumin is made by the liver only when
adequate amounts of amino acids (from protein breakdown) are available.
Albumin has a long half-life, so acute protein loss does not significantly
alter serum levels. Option B is a serum protein with a half-life of only 8 to
10 days, so it will drop with an acute protein deficiency. Options C and D
are not clinical measures of protein malnutrition.
In completing a client's preoperative routine, the nurse finds that the
operative permit is not signed. The client begins to ask more questions
about the surgical procedure. Which action should the nurse take next?
A. Witness the client's signature to the permit.
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, B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client
has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before
the anesthesia is administered. - 🧠 ANSWER ✔✔C
Rationale: The surgeon should be informed immediately that the permit is
not signed. It is the surgeon's responsibility to explain the procedure to the
client and obtain the client's signature on the permit. Although the nurse
can witness an operative permit, the procedure must first be explained by
the health care provider or surgeon, including answering the client's
questions. The client's questions should be addressed before the permit is
signed.
The nurse is assessing several clients prior to surgery. Which factor in a
client's history poses the greatest threat for complications to occur during
surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy