AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS | PLUS RATIONALES | GUARANTEED
PASS | LATEST EXAM UPDATE
*Core Domains*
*• Management of Care*
*• Safety and Infection Control*
*• Health Promotion and Maintenance*
*• Psychosocial Integrity*
*• Basic Care and Comfort*
*• Pharmacological and Parenteral Therap
*• Reduction of Risk Potential*
*• Physiological Adaptation*
*Introduction*
*This comprehensive assessment is designe
SECTION ONE: QUESTIONS 1–100
1. A nurse is caring for a client with a chest tube. The
nurse notices that the fluctuation in the water-seal
, chamber has stopped. Which action should the
nurse take first?
A. Increase the suction pressure
B. Check the tubing for kinks or clots
C. Strip the chest tube vigorously
D. Notify the healthcare provider immediately
🟢 B. Check the tubing for kinks or clots
🔴 Explanation: Fluctuation (tidaling) in the water-seal
chamber stops when the lung has fully re-expanded or if
there is an obstruction in the system, such as a kink or a
clot. Checking for an obstruction is the initial
assessment.
2. A client is admitted with an acute exacerbation of
heart failure. Which clinical manifestation should
the nurse expect to find?
A. Weight loss and increased urinary output
B. Flattened neck veins and bradycardia
,C. Bilateral crackles and peripheral edema
D. Increased appetite and hyper-metabolism
🟢 C. Bilateral crackles and peripheral edema
🔴 Explanation: Heart failure results in fluid volume
excess due to the heart's inability to pump effectively,
leading to pulmonary congestion (crackles) and systemic
venous congestion (edema).
3. The nurse is preparing to administer digoxin to a
client. Which laboratory result would require the
nurse to hold the medication?
A. Serum potassium 3.2 mEq/L
B. Serum sodium 140 mEq/L
C. Serum digoxin level 1.2 ng/mL
D. Serum calcium 9.5 mg/dL
🟢 A. Serum potassium 3.2 mEq/L
🔴 Explanation: Hypokalemia (potassium below 3.5
mEq/L) increases the risk of digoxin toxicity. The nurse
, must monitor potassium levels closely when
administering this medication.
4. A client who is 24 hours postoperative following a
total hip arthroplasty refuses to use the incentive
spirometer. Which statement by the nurse is most
appropriate?
A. You must use it to satisfy the doctor's orders.
B. If you don't use it, you will likely develop a blood clot.
C. It helps clear your lungs and prevents pneumonia.
D. I will have to document that you are being non-
compliant.
🟢 C. It helps clear your lungs and prevents pneumonia.
🔴 Explanation: Providing the rationale for an
intervention encourages client participation and
education regarding the prevention of respiratory
complications like atelectasis and pneumonia.
5. Which task is most appropriate for the RN to
delegate to an unlicensed assistive personnel