UPDATED EXAM ACTUAL LATEST VERSIONS
150 QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES (100%
CORRECT) A+ GRADED ASSURED
A 12-month-old child is playing with the father. Which of these behaviors indicates that the child
is demonstrating object permanence? - CORRECT ANSWER: The child looks for a toy that the
father has hidden under the table.
A 15-year-old child who has type I diabetes mellitus receives an injection of regular insulin 5
units and isophane (NPH) insulin 15 units subcutaneously at 7:00 A.M. before eating breakfast.
At 10:30 A.M., the child tells the school nurse, "I am sweating and feel weak." Which of these
actions should the nurse take first? - CORRECT ANSWER: Measure the blood sugar.
A 22-year-old college student has a heart rate that is 48/minute and regular during a routine
physical examination. Which of these questions should a nurse consider when analyzing this
heart rate? - CORRECT ANSWER: Is this student an athlete?
A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A nurse
should prepare the woman to have an immediate sonogram to determine the: - CORRECT
ANSWER: location of the placenta.
A 75-year-old client who is newly admitted to a long-term care facility has all these nursing
diagnoses. Which one is the priority? - CORRECT ANSWER: Risk of injury.
A child is brought to the clinical for serum lead screening because of ingestion of lead-based
paint. Which of these manifestations, if present in the child, would indicate early signs of lead
toxicity? - CORRECT ANSWER: Behavior changes.
,A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks.
To determine if the desired effects of the Pancrease are achieved, a nurse should consider which
of these questions? - CORRECT ANSWER: Are the child's stools of normal consistency?
A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A
nurse should interpret this to mean that the client has: - CORRECT ANSWER: been in relatively
good diabetic control.
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports
this diagnosis? - CORRECT ANSWER: Elevated serum amylase level.
A client has been in bed for the past three days. Which of these measures should a nurse include
before assisting the client out of bed? - CORRECT ANSWER: Raising the head of the bed.
A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these
measures should a nurse include in the client's care plan? - CORRECT ANSWER: Allowing the
client to eat food from sealed containers.
A client has shortness of breath when lying down and usually assumes an upright or sitting
position in order to breathe more comfortably. A nurse should document this observation as: -
CORRECT ANSWER: orthopnea.
A client has the following order for regular insulin (Humulin R) on a sliding scale:
Blood sugar 150-180 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin
Blood sugar 201-220 mg: Give 6 units of regular insulin
Blood sugar above 220 mg: Call MD
At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three
milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should
the nurse administer? - CORRECT ANSWER: 0.04
, A client is admitted for opiate detoxification for the fifth time. Which of these statements, if
made by a staff member, indicates a biased view of the client? - CORRECT ANSWER: "Addicts
relapse because they don't try hard enough."
A client is eight hours postoperative after a transurethral resection of the prostate (TURP). Which
of these observations, if noted by a nurse, indicates a complication? - CORRECT ANSWER: BP
92/60 mm Hg, pulse rate 118/minute.
A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my
kingdom. I am not taking any medications. I do not want anyone to come near me. I need to
protect myself if they do." Which of these problems should the nurse focus on first? - CORRECT
ANSWER: Risk for violence.
A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the
wrong thing and not get the job." Which of these responses, if made by the nurse, will create a
communication barrier? - CORRECT ANSWER: "You need to relax, and everything will be
fine."
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding
and take which of these actions? - CORRECT ANSWER: Check the residual volume.
A client who had a coronary artery bypass graft four days ago suddenly develops sinus
tachycardia and reports shortness of breath and dizziness. Which of these interpretations and
actions should a nurse take? - CORRECT ANSWER: This may be an early sign of heart failure;
notify the physician.
A client who has a breast tumor says to a nurse, "I am so anxious. Why did I have to get sick
now?" Which of these responses, if made by the nurse, is therapeutic? - CORRECT ANSWER:
"Tell me more about your concerns."
A client who has a head injury is drowsy and lethargic, and has clear nasal discharge. Which of
these actions should a nurse take? - CORRECT ANSWER: Test the drainage for glucose.