EXAM ALL 60 QUESTIONS AND CORRECT ANSWERS
(VERIFIED SOLUTIONS) | NEWEST UPDATE 2026/2027 |
GRADED A+.
A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a
long-term care facility. Using this scale, which of the following parameters should
the nurse evaluate? 1. incontinence
2. mental state
3. nutrition
4. general physical condition
- ANSWER- Nutrition ; nutrition, sensory perception, moisture, activity, mobility,
and friction and shear are the parameters of the Braden scale for determining a
client's risk for developing pressure ulcers. Incontinence, mental state, and general
physical condition are parameters on the Norton scale.
A nurse is caring for a client who is immobile. The nurse should recognize that immobility
places the client at risk for which of the following health alterations?
1. increased intestinal motility
2. respiratory alkalosis
3. decreased cardiac output
4. hypocalcemia
- ANSWER- Decreased cardiac output ; with immobility, the heart rate increases
to compensate for increased venous pooling. Hypoventilation will lead to CO2
retention and respiratory acidosis.
A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse should
identify that which of the following nutrients will be affected by the lack of salivary
amylase?
1. fat
2. protein
3. starch
4. fiber
- ANSWER- Starch ; majority of starch breakdown occurs in the small intestine
with pancreatic amylase. Lipase breaks down fats. Pepsin breaks down
proteins.
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,A nurse is caring for a client who has a deficiency in vitamin D. Which of the following
foods should the nurse recommend the client include in his diet?
1. whole milk
2. chicken
3. oranges
4. dried peas
- ANSWER- Whole milk ; it is often fortified with vitamin D and contains
vitamins A and K. Chicken contains many of the B complex vitamins. Oranges
are a good source of vitamin C.
A nurse is planning to administer diphenhydramine hydrochloride to an older adults
client. Which of the following actions should the nurse take prior to administration?
1. review the client's medical record for a history of glaucoma
2. plan to administer medication 30 minutes before a meal
3. explain that he will need to restrict his fluid intake
4. remind the client that his appetite might increase when starting the medications
-ANSWER- Review the client's medical record for a history of glaucoma ;
diphenhydramine is contraindicated for clients who have narrow-angle glaucoma. The
client should increase fluid intake. Anorexia, nausea, and vomiting are GI adverse
effects of this medication.
A nurse is reinforcing teaching with an older adult client who has constipation. Which
of the following statements should the nurse include in the teaching?
1. Drink minimum 1L of fluid daily
2. increase your intake of refined-fiber foods
3. sit on the toilet 30 minutes after eating a meal
4. take a laxative every day to maintain regularity
- ANSWER- Sit on the toilet 30 min after eating a meal ; increased peristalsis
occurs after food enters the stomach. This is a recommended method of bowel
retraining to treat constipation. Consume at least 1.5L of fluid. Increase
consumption of coarse fiber and whole grains. A nurse is caring for a client who
has peripheral edema. The nurse should identify that which of the following
nutrients regulates extracellular fluid volume?
1. sodium
2. calcium
3. potassium
4. magnesium
- ANSWER- Sodium ; regulates extracellular fluid balance as well as
nerve impulse transmission, acid-base balance.
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, A nurse is caring for an older adult client who has a hip fracture and is rating his pain
8/10. Which of the following medications should the nurse administer?
1. capsaicin topical gel
2. oxycodone/acetaminophen
3. celecoxib
4. aspirin
- ANSWER- Oxycodone/acetaminophen ; this is a combination of an opioid and
nonopioid analgesic for severe pain. Monitor for adverse effects such as
respiratory depression.
1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense
sadness are symptoms of which stage? a. Denial and isolation
b. Depression
c. Anger
d. Bargaining
RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining,
depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate
depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and others. In
bargaining, the client asks God for more time, and in return promises to do something good.
2. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall
c. provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.
RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore,
encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or
repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and
supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because
the additional calcium doesn’t increase bone stimulation or osteoblast activity.
3. Which statement regarding heart sounds is correct?
a. S1 and s2 sound equally loud over the entire cardiac area.
b. S1 and sound fainter at the apex than at the base.
c. S and 2 sound fainter at the base than at the apex.
d. S1 is loudest at the apex, and S2 is loudest at the base.
Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than
the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.
4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing.
When planning this client’s care, the nurse should include which intervention? a. Increasing
fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough
c. Improving airway clearance
d. Suctioning the client every 2 hours
RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and
coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor
coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated
unless other measures fail to clear the airway.
8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which
action should the nurse take first? a. Discontinue the I.V. infusion.
b. Apply a warm, moist compress to the I.V. site.
c. Assess the I.V. infusion for patency.
d. Apply an ice pack to the I.V. site.
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