UPDATED AND RATIONALES 2026 LATEST!!!!!!!!!
The nurse determines a new mother is in greatest need of more education about
infant care and safety when the mother states:
1. "I am pretty sure that I am going to breastfeed my baby."
2. "After feeding, the baby should be put on her tummy to prevent choking."
3. "Solid foods are not necessary during the baby's first 4 to 6 months."
4. "My baby will sleep frequently and should be awakened every 3 to 4 hours for
feeding." - ANS... -2 - Infants should always be put to sleep on the back
The result of a toddler's lead screening is 12mg/dL. The nurse should say which of
the following to the mother at this time?
1. "His lab values are just fine."
2. "Have you noticed any blood in his stools?"
3. "When were his last immunizations?"
4. "Tell me about where you live." - ANS... -4 - The lead value of 12mg/dL is high.
Lead levels below 10mg/dL are acceptable. Levels of 10-19mg/dL require an
environmental history. Levels above 20mg/dL require a full medical evaluation.
Asking a question regarding the child's address is the first step in evaluating the
environment. Older homes may have lead paint and lead in the plumbing
When planning for discharge from the birthing center on the following day, the
nurse learns that the father will drive the new mother and infant home. When
teaching the new parents about infant restraint systems, the nurse should include
that the restraint system be (select all that apply):
1. Forward facing
2. Rear facing
3. In the back seat
4. In the front seat
5. Of a bland or neutral color - ANS... -2, 3 - A child restraint system should
always be in the back seat and rear facing. After a child is 1 year of age and 20
pounds, the seat may be in the rear and front facing. Although bright colors are
stimulating to an infant, the color of the system does not matter
Which of the following snacks should the nurse offer the hospitalized toddler?
1. Crackers
2. Peanuts
,3. Grapes
4. Cereal bar - ANS... -1 - Crackers are a soft consistency when chewed and
swallowed. Toddlers can easily choke on small foods such as peanuts, popcorn,
and grapes, and on firm consistency foods such as cereal bars
What is the best method for the nurse to use to encourage the use of bicycle
helmets by school-aged children?
1. Advocate for legislation on helmet laws.
2. Teach parents to role-model helmet use while riding bicycles
3. Verbally reprimand children who report not wearing helmets while riding.
4. Recommend the parents purchase stylish helmets to increase compliance -
ANS... -2 - Parent role models of behavior are the best method to develop good
habits in children.
A school nurse is planning a health class on accidents and injuries for a high school
class. Which topic is most important to include?
1. Occupational-related injuries at work
2. Motor vehicle-related injuries
3. Fall-related injuries
4. Injury due to residential fires - ANS... -2 - Driving a car and having the
independence to ride with friends is an important milestone for high school-aged
adolescents. Some adolescents experiment with alcohol and drugs, putting them at
increased risk for motor vehicle accidents
The home health nurse is visiting an elderly client with diabetes mellitus. The
nurse becomes concerned and implements safety education when which of the
following occurs?
1. The neighbors bring a warm lunch to the elderly client.
2. The children install new air-conditioning units in the kitchen and bedroom.
3. The grandchildren fold laundry and place the baskets by the door to the
bedroom.
4. The client stores the diabetic testing supplies on the kitchen table. - ANS... -3 -
Laundry baskets that are set on the floor will pose a risk for falling for the elderly
client. All hallways, floors, stairways, and furniture should be free of clutter.
Neighbors bringing lunch and family controlling climate for the elderly client are
good safety interventions. Keeping diabetic supplies on a kitchen table with easy
access will facilitate diabetic testing
,A client is referred to a surgeon by the general practitioner. After meeting the
surgeon, the client decides to find a different surgeon to continue treatment. The
nurse supports the client's action, utilizing which ethical principle
1. Beneficence
2.Veracity
3. Autonomy
4. Privacy - ANS... -Answer 3: Autonomy is the right of individuals to take action
for themselves. Beneficence is duty to help others by doing what is best for them,
whereas negligence is a legal term. Veracity is truthfulness. Privacy is the
nondisclosure of information by the health care team.
A nurse forgets to administer a client's diuretic and the client experiences an
episode of pulmonary edema. This medication error would be considered
negligence if it constituted which of the following?
1. The purposeful failure to perform a health care procedure
2. The unintentional failure to perform a health care procedure
3. The act of substituting a different medication for the one ordered</choice
4. Failure to follow a direct order by a physician - ANS... -Answer 2: Negligence is
the unintentional failure of an individual to perform or not perform an act that a
reasonable person would or would not do in the same or similar circumstances.
A new graduate nurse orientee plans to show an adolescent client a video about
self-injection technique. A staff nurse remarks, "I gave the client written literature
yesterday, so the video probably isn't necessary." The nurse orientee proceeds with
showing the video and discussing the skill with the adolescent after engaging in
decision making related to which of the following?
1. Autonomy
2. Informed consent
3. Paternalism
4. Noncompliance - ANS... -1 - The nurse is exercising autonomy, the right to
make one's own decision. Nurses who follow this principle recognize that each
client is unique. In this situation, perhaps because of the developmental level, the
nurse assessed that a video would be a better teaching-learning method than
written literature. Paternalism restricts the freedom of the individual because
another determines choices. Noncompliance occurs when an individual is fully
aware of the consequences yet chooses the action anyway. Informed consent is
providing agreement to undergo treatment following a description of a procedure
with the risks, benefits, and alternatives explained.
, A client asks why a diagnostic test has been ordered and the nurse replies, "I'm
unsure but will find out for you." When the nurse later returns and provides an
explanation, the nurse is acting under which principle?
1. Nonmaleficence
2. Veracity
3. Beneficence
4. Fidelity - ANS... -4. - Fidelity means to be faithful to agreements and promises.
This nurse is acting on the client's behalf to obtain needed information and report it
back to the client. Nonmaleficence is duty to do no harm. Veracity refers to telling
the truth. Beneficence means doing good
An individual has a seizure while walking down the street. During the seizure, a
nurse from a physician's office is noticed driving past without stopping to assist.
The individual sues the nurse for negligence but fails to win a judgment for which
of the following reasons
1. The nurse had no duty to the individual.
2. The nurse did what most nurses would do in the same circumstance.
3. The nurse did not cause the client's injuries.
4.The nurse was off-duty at that time - ANS... -1. The nurse must have a
relationship with the client that involves providing care
The nurse is participating in a seminar about legal and ethical practice of nursing
for continuing education credit. Which statement by a nurse best describes the
relationship between law and ethics for the practice of nursing?
1. "The ethics of a discipline attempt to formulate and justify responses to moral
dilemmas and may or may not be regulated by law."
2. "Laws dictate the ethics of nursing as they reflect societal choices about the
ordering of relationships in society."
3. "Ethics represent the moral customs of an individual nurse; therefore, they
cannot be regulated by the law."
4. "Ethical practice decreases the threat of a lawsuit, which is the primary source of
legal influence on nursing practice." - ANS... -1. Rationale: Law is not the sole
source of the ethical practice of nursing; numerous legal sources influence nursing
practice. An individual should understand the ethics of a profession before
becoming a member of that profession because those ethics may differ from
personal ones.</rationale>
The client has decided to discontinue further treatment for cancer. Although the
nurse would like the client to continue treatment, the nurse recognizes the client is