NUR 5061 MDC 1 Final | Actual Study Questions and
verified Answers with Rationale | A+ Graded | 2026
Updates | 100% Correct
1) An adult client with a history of diabetes is scheduled for a transmetatarsal
amputation. When should the client's discharge planning begin?
A. The day prior to discharge
B. The day of estimated discharge
C. The day that the client is admitted
D. Once the nursing care plan has been finalized
ANS: C
Rationale: Discharge planning begins with the client's admission to the hospital and must
consider the possible need for follow-up home care. Discharge planning should begin prior to
the other listed times.
2) A school nurse is teaching a 14-year-old girl of normal weight some of the key factors
necessary to maintain good nutrition in this stage of growth and development. What
interventions should the nurse prioritize to the client?
A. Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity
B. Increasing her BMI, taking a multivitamin, and discussing body image
C. Increasing calcium intake, eating a balanced diet, and discussing eating disorders D.
Obtaining a food diary along with providing close monitoring for anorexia
ANS: C
Rationale: Adolescent girls are considered to be at high risk for nutritional disorders. Increasing
calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals.
If adolescents are diagnosed with eating disorders early, they have a better chance of recovery.
The question presents no information that indicates a need for decreasing the client’s calories.
There is no apparent need for an increase in BMI. A food diary is used for assessing eating
habits, but the question asks for teaching factors related to good nutrition.
3) The nurse is assessing a 28-year-old client who has presented to the emergency
department with vague reports of malaise. The nurse observes bruising to the client's
upper arm that corresponds to the outline of fingers as well as yellow bruising around
,the left eye. The client makes minimal eye contact during the assessment. How should
the nurse best inquire about the bruising?
A. "Is anyone physically hurting you?"
B. "Tell me about your relationships."
C. "Do you want to see a social worker?"
D. "Is there something you want to tell me?"
ANS: A
Rationale: Few clients will discuss the topic of violence unless they are directly asked.
Therefore, it is important to ask direct questions, such as, "Is anyone physically hurting you?"
The other options are incorrect because they are not the best way to elicit information about
possible violence in a direct and appropriate manner.
4) The nurse is performing a health history on a client. Which question will the nurse ask
to elicit information about past health history?
A. “Have you ever had surgery?”
B. “What brought you to the hospital today?”
C. “How is the health of your parents?”
D. “Are you in any pain?”
ANS: A
Rationale: Asking the client about health history elicits information about immunizations,
allergies, surgeries, and illnesses. Asking why the client is seeking health care today is
addressing a present health concern. Asking about the health of the client’s parents is
addressing family history. Asking about pain is also addressing the present health concern.
5) When caring for a client who predominantly identifies with another culture than the
nurse, how can the nurse best demonstrate an awareness of culturally congruent care?
A. Maintain eye contact at all times.
B. Try to speak the client's primary language.
C. Use touch when communicating.
D. Establish effective communication.
ANS: D
Rationale: Establishment of an environment of culturally congruent care and respect begins
with effective communication, which occurs not only through words, but also through body
language and other cues, such as voice, tone, and loudness. Not all cultures are comfortable
with eye contact. Unless the nurse is fluent in the client's primary language, trying to
communicate in that language would not be effective communication. Not all cultures
incorporate touch while communicating.
,6) The nurse is applying standard precautions in the care of a client who has an
immunodeficiency. What are key elements of standard precautions? (Select all that
apply.)
A. Using appropriate personal protective equipment
B. Placing clients in negative pressure isolation rooms
C. Placing clients in positive pressure isolation rooms
D. Using safe injection practices
E. Performing hand hygiene
ANS: A, D, E
Rationale: Some of the key elements of standard precautions include performing hand
hygiene; using appropriate personal protective equipment, depending on the expected type of
exposure; and using safe injection practices. Isolation is an infection control strategy but is not a
component of standard precautions.
7) A nurse caring for a client who has an immunosuppressive disorder knows that
continual monitoring of the client is critical. What is the primary rationale behind the
need for continual monitoring?
A. So that the client's functional needs can be met immediately
B. So that medications can be given as prescribed and signs of adverse reactions noted
C. So that early signs of impending infection can be detected and treated
D. So that the nurse's documentation can be thorough and accurate
ANS: C
Rationale: Continual monitoring of the client's condition is critical, so that early signs of
impending infection may be detected and treated before they seriously compromise the client's
status. Continual monitoring is not primarily motivated by the client's functional needs or
medication schedule. The nurse's documentation is important, but less so than infection control.
8) A nurse is assessing a client with HIV who has been admitted with pneumonia. In
assessing the client, which of the following observations takes immediate priority?
A. Oral temperature of 37.2°C (99°F)
B. Tachypnea and restlessness
C. Frequent loose stools
D. Weight loss of 0.45 kg (1 lb) since yesterday
ANS: B
Rationale: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory
status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose
, stools would not take short-term precedence over a temperature or tachypnea and restlessness.
An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue
addressed.
9) A nurse is working with a client who was diagnosed with HIV several months earlier.
This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops
below what threshold? A. 75 cells/mm3 of blood
B. 200 cells/mm3 of blood
C. 325 cells/mm3 of blood
D. 450 cells/mm3 of blood
ANS: B
Rationale: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to
have AIDS.
10) Family members are caring for a client with HIV in the client's home. What should the
nurse encourage family members to do to reduce the risk of infection transmission? A.
Use caution when shaving the client.
B. Use separate dishes for the client and family members.
C. Use separate bed linens for the client.
D. Disinfect the client's bedclothes regularly.
ANS: A
Rationale: When caring for a client with HIV at home, family members should use caution
when providing care that may expose them to the client's blood, such as shaving. Dishes, bed
linens, and bedclothes, unless contaminated with blood, only require the usual cleaning.
11) A nurse is planning the care of a client with acquired immunodeficiency syndrome
(AIDS) who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing
diagnosis has the highest priority for this client?
A. Ineffective airway clearance
B. Impaired oral mucous membranes
C. Imbalanced nutrition: Less than body requirements
D. Activity intolerance
ANS: A
Rationale: Although all these nursing diagnoses are appropriate for a client with AIDS,
Ineffective Airway Clearance is the priority nursing diagnosis for the client with PCP. Airway and
breathing take top priority over the other listed concerns because of the immediacy of the health
consequences.
verified Answers with Rationale | A+ Graded | 2026
Updates | 100% Correct
1) An adult client with a history of diabetes is scheduled for a transmetatarsal
amputation. When should the client's discharge planning begin?
A. The day prior to discharge
B. The day of estimated discharge
C. The day that the client is admitted
D. Once the nursing care plan has been finalized
ANS: C
Rationale: Discharge planning begins with the client's admission to the hospital and must
consider the possible need for follow-up home care. Discharge planning should begin prior to
the other listed times.
2) A school nurse is teaching a 14-year-old girl of normal weight some of the key factors
necessary to maintain good nutrition in this stage of growth and development. What
interventions should the nurse prioritize to the client?
A. Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity
B. Increasing her BMI, taking a multivitamin, and discussing body image
C. Increasing calcium intake, eating a balanced diet, and discussing eating disorders D.
Obtaining a food diary along with providing close monitoring for anorexia
ANS: C
Rationale: Adolescent girls are considered to be at high risk for nutritional disorders. Increasing
calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals.
If adolescents are diagnosed with eating disorders early, they have a better chance of recovery.
The question presents no information that indicates a need for decreasing the client’s calories.
There is no apparent need for an increase in BMI. A food diary is used for assessing eating
habits, but the question asks for teaching factors related to good nutrition.
3) The nurse is assessing a 28-year-old client who has presented to the emergency
department with vague reports of malaise. The nurse observes bruising to the client's
upper arm that corresponds to the outline of fingers as well as yellow bruising around
,the left eye. The client makes minimal eye contact during the assessment. How should
the nurse best inquire about the bruising?
A. "Is anyone physically hurting you?"
B. "Tell me about your relationships."
C. "Do you want to see a social worker?"
D. "Is there something you want to tell me?"
ANS: A
Rationale: Few clients will discuss the topic of violence unless they are directly asked.
Therefore, it is important to ask direct questions, such as, "Is anyone physically hurting you?"
The other options are incorrect because they are not the best way to elicit information about
possible violence in a direct and appropriate manner.
4) The nurse is performing a health history on a client. Which question will the nurse ask
to elicit information about past health history?
A. “Have you ever had surgery?”
B. “What brought you to the hospital today?”
C. “How is the health of your parents?”
D. “Are you in any pain?”
ANS: A
Rationale: Asking the client about health history elicits information about immunizations,
allergies, surgeries, and illnesses. Asking why the client is seeking health care today is
addressing a present health concern. Asking about the health of the client’s parents is
addressing family history. Asking about pain is also addressing the present health concern.
5) When caring for a client who predominantly identifies with another culture than the
nurse, how can the nurse best demonstrate an awareness of culturally congruent care?
A. Maintain eye contact at all times.
B. Try to speak the client's primary language.
C. Use touch when communicating.
D. Establish effective communication.
ANS: D
Rationale: Establishment of an environment of culturally congruent care and respect begins
with effective communication, which occurs not only through words, but also through body
language and other cues, such as voice, tone, and loudness. Not all cultures are comfortable
with eye contact. Unless the nurse is fluent in the client's primary language, trying to
communicate in that language would not be effective communication. Not all cultures
incorporate touch while communicating.
,6) The nurse is applying standard precautions in the care of a client who has an
immunodeficiency. What are key elements of standard precautions? (Select all that
apply.)
A. Using appropriate personal protective equipment
B. Placing clients in negative pressure isolation rooms
C. Placing clients in positive pressure isolation rooms
D. Using safe injection practices
E. Performing hand hygiene
ANS: A, D, E
Rationale: Some of the key elements of standard precautions include performing hand
hygiene; using appropriate personal protective equipment, depending on the expected type of
exposure; and using safe injection practices. Isolation is an infection control strategy but is not a
component of standard precautions.
7) A nurse caring for a client who has an immunosuppressive disorder knows that
continual monitoring of the client is critical. What is the primary rationale behind the
need for continual monitoring?
A. So that the client's functional needs can be met immediately
B. So that medications can be given as prescribed and signs of adverse reactions noted
C. So that early signs of impending infection can be detected and treated
D. So that the nurse's documentation can be thorough and accurate
ANS: C
Rationale: Continual monitoring of the client's condition is critical, so that early signs of
impending infection may be detected and treated before they seriously compromise the client's
status. Continual monitoring is not primarily motivated by the client's functional needs or
medication schedule. The nurse's documentation is important, but less so than infection control.
8) A nurse is assessing a client with HIV who has been admitted with pneumonia. In
assessing the client, which of the following observations takes immediate priority?
A. Oral temperature of 37.2°C (99°F)
B. Tachypnea and restlessness
C. Frequent loose stools
D. Weight loss of 0.45 kg (1 lb) since yesterday
ANS: B
Rationale: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory
status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose
, stools would not take short-term precedence over a temperature or tachypnea and restlessness.
An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue
addressed.
9) A nurse is working with a client who was diagnosed with HIV several months earlier.
This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops
below what threshold? A. 75 cells/mm3 of blood
B. 200 cells/mm3 of blood
C. 325 cells/mm3 of blood
D. 450 cells/mm3 of blood
ANS: B
Rationale: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to
have AIDS.
10) Family members are caring for a client with HIV in the client's home. What should the
nurse encourage family members to do to reduce the risk of infection transmission? A.
Use caution when shaving the client.
B. Use separate dishes for the client and family members.
C. Use separate bed linens for the client.
D. Disinfect the client's bedclothes regularly.
ANS: A
Rationale: When caring for a client with HIV at home, family members should use caution
when providing care that may expose them to the client's blood, such as shaving. Dishes, bed
linens, and bedclothes, unless contaminated with blood, only require the usual cleaning.
11) A nurse is planning the care of a client with acquired immunodeficiency syndrome
(AIDS) who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing
diagnosis has the highest priority for this client?
A. Ineffective airway clearance
B. Impaired oral mucous membranes
C. Imbalanced nutrition: Less than body requirements
D. Activity intolerance
ANS: A
Rationale: Although all these nursing diagnoses are appropriate for a client with AIDS,
Ineffective Airway Clearance is the priority nursing diagnosis for the client with PCP. Airway and
breathing take top priority over the other listed concerns because of the immediacy of the health
consequences.
