799 2023–2026 | Questions,
Answers & Detailed
Rationales Study Guide
|Graded A+ | Guaranteed
success|
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,The nurse observes an unlicensed assistive personnel b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
(UAP) positioning a newly admitted client who has a pillows.
seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action
should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively
to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to
the side rails instead of pillows.
c. Assume responsibility for placing the pillows while the
UAP completes another task.
d. Ask the UAP to use some of the pillows to prop the
client in a side lying position.
A male client with hypertension, who received new c. Stroke secondary to hemorrhage
antihypertensive prescriptions at his last visit returns to
the clinic two weeks later to evaluate his blood pressure
(BP). His BP is 158/106 and he admits that he has not been
taking the prescribed medication because the drugs
make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an
elevated BP places the client at risk for which
pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
An adolescent with major depressive disorder has been a. Describes life without purpose
taking duloxetine (Cymbalta) for the past 12 days. Which
assessment finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
, A 60-year-old female client with a positive family history a. Further evaluation involving surgery may be needed
of ovarian cancer has developed an abdominal mass and
is being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What
information should the nurse include in the client's
teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled
out
c. Pap smear evaluation should be continued every six
month
d. One additional negative pap smear in six months is
needed.
A client who recently underwent a tracheostomy is being b. Teach tracheal suctioning techniques
prepared for discharge to home. Which instructions is
most important for the nurse to include in the discharge
plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
In assessing an adult client with a partial rebreather mask, d. Document the assessment data
the nurse notes that the oxygen reservoir bag does not
deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should
the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
During shift report, the central electrocardiogram (EKG) a. Respiratory apnea of 30 seconds
monitoring system alarms. Which client alarm should the
nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
During a home visit, the nurse observed an elderly client c. Check the client for lacerations or fractures
with diabetes slip and fall. What action should the nurse
take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level