form A GRADED A LATEST VERSION
2023/2024 253 QUESTIONS AND
ANSWERS
A nurse is caring for four clients. Which of the following client statements should the
nurse attend to first? - CORRECT ANSWER "My heartburn pain is going into my jaw
now."
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal
tube. Which of the following actions should the nurse take? - CORRECT ANSWER
Perform oral care every 2 hr.
A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the
following laboratory values should the nurse check prior to administering the
medication? - CORRECT ANSWER - PT
- INR
A nurse is collecting data from a client who is at 9 weeks of gestation and has
hyperemesis gravidarum. Which of the following findings should the nurse expect? -
CORRECT ANSWER Weight loss
A nurse is reinforcing teaching with a client about the importance of a low sodium diet.
Which of the following foods should the nurse recommend as the best choice to include
in a low sodium diet? - CORRECT ANSWER 2 tbsp of peanut butter
A nurse is collecting data from an 18 month old toddler at a well child visit. Which of the
following findings should the nurse report to the provider? - CORRECT ANSWER The
toddler can say four words.
A nurse is collecting data from a client who has diabetes mellitus. Which of the following
findings indicates that the client might be experiencing diabetic ketoacidosis? -
CORRECT ANSWER Kussmaul respirations
A nurse is reinforcing teaching with a client who has a permanent pacemaker in place.
Which of the following statements by the client indicates an understanding of the
teaching? - CORRECT ANSWER "I need to record my pulse rate daily."
A nurse is caring for a client who is in mechanical restraints after becoming violent with
a staff member. Which of the following actions should the nurse take? - CORRECT
ANSWER Document in the clients medical record every 15 min.
, A nurse is reinforcing teaching about self-administration of nasal drops with a client.
Which of the following positions should the nurse recommend for instillation of the
drops? - CORRECT ANSWER Supine
A nurse is preparing to administer furosemide to a client who has heart failure. Which of
the following laboratory results should the nurse review prior to administering the
medication? - CORRECT ANSWER Potassium
A nurse is caring for a client who has methicillin-resistant staphylococcus aureus
(MRSA) infection. Which of the following actions should the nurse plan to take? -
CORRECT ANSWER Don a gown and gloves when providing perineal care
A nurse is assisting with the plan of care for a client who has dementia and often
wanders in the halls at night. Which of the following interventions should the nurse
recommend including in the plan of care? - CORRECT ANSWER Labeling the clients
bathroom door
A charge nurse is reinforcing teaching with a newly hired licensed practical nurse about
scope of practice. Which of the following responsibilities should the nurse include in the
teaching? - CORRECT ANSWER Providing direct client care
A nurse is working on a mental health unit is meeting with a client who has been in the
unit for 2 days. The nurse greets the client and asks, "What has been happening with
you today?" Which of the following therapeutic techniques is the nurse using? -
CORRECT ANSWER Reflecting
A nurse us reinforcing teaching with a group of expectant parents regarding the proper
use of a car seat. Which of the following statements by a parent indicates an
understanding of the teaching? - CORRECT ANSWER "I will secure the seat belt
across my newborns lap."
A nurse from a medical surgical unit is floating to a postpartum unit. Which of the
following clients is an appropriate assignment for the nurse to accept? - CORRECT
ANSWER A client who underwent removal of a retained placenta
A nurse is assisting with planning care for a newly admitted client who has anorexia
nervosa. Which of the following interventions should the nurse recommend to include in
the plan of care? - CORRECT ANSWER Reinforce teaching about healthy eating
during meals
A nurse is admitting a client who is scheduled for an elective surgery. Which of he
following actions should the nurse take to verify the status of the clients advance
directives? - CORRECT ANSWER Ask the client whether they have advance directives