UPDATED ACTUAL Questions and
CORRECT Answers
A nurse is assisting with the care of a patient who is receiving a unit of packed RBCs
The patient has manifestations of ____ as evidenced by the patient's _____- - CORRECT
ANSWER - allergic reaction, itching
A nurse in an emergency department (ED) is assisting with the care of a patient.
What findings indicate the patient might be malnourished? - CORRECT ANSWER - - patient is
cachectic with flaccid muscle tone
- skin is dry and scaly with bruises on extremities
-pulse rate 118/min
- abdomen is distended
- BMI 17
A nurse is assisting in the care of a patient who has pancreatitis.
Select 3 tasks the nurse should delegate to an assistive personnel (AP) - CORRECT ANSWER - 1.
measure the patient's intake and output
2. Document the patient's vital signs
3. Transfer the patient from a wheelchair to the bed
, A nurse is caring for a patient who has chronic kidney disease. The nurse should identify that which of the
following findings is the priority to report to the provider? - CORRECT ANSWER - The patient's
output was 60 mL for the past 3 hours
*this represents oliguria and can indicate a decrease in kidney perfusion or function
A nurse is preparing to administer an enteral feeding to a patient who has an NG tube in place. Which of
the following methods should the nurse use to verify correct placement of the NG tube? - CORRECT
ANSWER - check the gastric pH of the gastric aspirate
A nurse is repositioning a patient who has quadriplegia and is in the supine position. Which of the
following actions should the nurse take to prevent patient musculoskeletal injury? - CORRECT
ANSWER - internally rotate the patient's hips by using a trochanter roll
A nurse is preparing to palpate a patient's pulse. The nurse should recognize that which of the following
pulses is located on the top of the patient's foot? - CORRECT ANSWER - dorsalis pedis
A patient who is scheduled to undergo surgery tells the nurse that they do not understand the procedure
and are reconsidering their decision to have it. Which of the following actions should the nurse take? -
CORRECT ANSWER - notify the charge nurse of the patient's concerns
A nurse is reinforcing preoperative teaching with a patient about how to turn, cough, and deep breathe.
Which of the following statements by the patient indicates an understanding of the teaching? - CORRECT
ANSWER - "this can help prevent pneumonia"
A nurse is preparing to document information about a patient's lower legs, which are swollen with 6 mm
edema. Which of the following information should the nurse document? - CORRECT ANSWER -
3+ pitting edema
A nurse is checking for a patient's pulse deficit after detecting an irregular heart rate. Which of the
following actions should the nurse take? - CORRECT ANSWER - count the patient's radial and
apical pulses simultaneously with another nurse