VERIFIED ANSWERS LATEST UPDATE 2026-2027 ASSURED
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The nurse is caring for clients in the skilled nursing facility. Which of the
following clients require the nurse's IMMEDIATE attention?
1. A client admitted for a cerebral vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two days ago.
2. A client in pain who was receiving morphine in an acute care institution and was
transferred with a prescription for acetaminophen with codeine.
3. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
4. An immunosuppressed client who has not received an influenza immunization. -
ANS... -1
The nurse is observing care given to a client experiencing severe to
panic levels of anxiety. The nurse would intervene in which of the following
situations?
1. The staff maintains a calm manner when interacting with the client.
2. The staff attends to client's physical needs as necessary.
3. The staff helps the client identify thoughts or feelings that occurred prior to the
onset of the anxiety.
4. The staff assesses the client's need for medication or seclusion if other
interventions have failed to reduce anxiety. - ANS... -3
A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
1. The client complains of pain during the inflow of the dialysate.
2. The client complains of constipation.
3. The dialysate outflow is cloudy.
4. There is blood-tinged fluid around the intra-abdominal catheter. - ANS... -3
The clinic nurse is performing diet teaching with a 67-year-old client
with acute gout. The nurse should teach the client to limit his intake of
1. red meat and shellfish.
2. cottage cheese and ice cream.
3. fruit juices and milk.
4. fresh fruits and uncooked vegetables. - ANS... -1
,A client is scheduled for a left lower lobectomy. The physician has
ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine
that the medication is appropriate if the client displays which of the
following symptoms?
1. Agitation and decreased level of consciousness.
2. Lethargy and decreased respiratory rate.
3. Restlessness and increased heart rate.
4. Hostility and increased blood pressure. - ANS... -3
A 59-year-old woman with bipolar disorder is receiving haloperidol
(Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my
breasts." Which of the following responses by the nurse is BEST?
1. "You are seeing things that aren't real."
2. "Why don't we go make some fudge."
3. "You are experiencing a side effect of Haldol."
4. "I'll contact your physician to change your medication." - ANS... -3
The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for
a client. The nurse should advise the client the BEST time to take this
medication is
1. before breakfast.
2. with dinner.
3. with food.
4. at hs. - ANS... -4
. If a client develops cor pulmonale (right-sided heart failure), the nurse
would expect to observe
1. increasing respiratory difficulty seen with exertion.
2. cough productive of a large amount of thick, yellow mucus.
3. peripheral edema and anorexia.
4. twitching of extremities. - ANS... -3
The nurse is performing triage on a group of clients in the emergency
department. Which of the following clients should the nurse see FIRST?
1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a
rusty metal can.
2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister
but not the place
and time.
,3. A 49-year-old with a compound fracture of the right leg who is complaining of
severe pain.
4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of
470 mg/dL. - ANS... -2
The nurse in the outpatient clinic teaches a client with a sprained right
ankle to walk with a cane. What behavior, if demonstrated by the client,
would indicate that teaching was effective?
1. The client advances the cane 18 inches in front of her foot with each step.
2. The client holds the cane in her left hand.
3. The client advances her right leg, then her left leg, and then the cane.
4. The client holds the cane with her elbow flexed 60°. - ANS... -2
A client returns to his room following a myelogram. The nursing care
plan should include which of the following?
1. Encourage oral fluid intake.
2. Maintain the prone position for 12 hours.
3. Encourage the client to ambulate after the procedure.
4. Evaluate the client's distal pulses on the affected side. - ANS... -1
What can be delegated to Assistive personnel (AP)? (Topic 4) - ANS... -- ADLs -
bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) -
positioning - bed making - specimen collection - I&O - VS (stable clients
A nurse on a med surge unit has recieved change of shift report and will care for 4
clients. Which of the following clients needs will the nurse assign to an AP? (Topic
4)
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer - ANS... -C
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days
ago to an AP. Which of the following info should the nurse share with the AP?
(Topic 4)
Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
, D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning - ANS... -B
C
D
An RN is making assignments for client care to an LPN at the beginning of the
shift. Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hr postop to use an incentive spirometer
B. Collecting a clean catch urine specimen from a client who was admitted on the
previous shift
C. providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump - ANS... -D
A nurse is preparing an inservice program about delegation. Which of the
following elements should she identify when presenting the 5 rights of delegation.
Select all: (Topic 26)
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances - ANS... -B
C
E
A nurse manager of a med surge unit is assigning care responsibilities for the
oncoming shift. A client is waiting transfer back to the unit from the PACU
following thoracic surgery. To which staff member should the nurse assign the
client?
A. Charge nurse
B. RN
C. LVN
D. AP - ANS... -B
What is the study of conduct and character? - ANS... -Ethics
What are the values and beliefs that guide behavior and decision making? - ANS...
-Morals