QUESTIONS AND ANSWERS WITH RATIONALES | LATEST 2023
• A nurse is reviewing the techniques for transferring a client from a bed to a chair
with a group of assistive personnel (AP). Which of the following instructions
should the nurse include?
ANS: Use lower-body strength
RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a
client toreduce stress on the back
• A nurse is participating in a quality improvement study about the effectiveness of
client pain management in the unit. Which of the following strategies should the
nurse use to collect data?
ANS: Review clients' charts for their rating of pain before pain medication was administered
and 1 hr after administration
RATIONALE: The nurse should collect data from clients' charts about pain ratings before and
afterpain management interventions
• A nurse is reinforcing teaching about confidentiality with a client who has a new
diagnosis of HIV. Which of the following information should the nurse include in
the teaching?
ANS: "Your HIV status will be shared with members of your health care team."
RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare
team who provides direct care for the client, just like any other diagnoses
• A nurse is planning care for a client who has a history of seizures. Which of the
following pieces of equipment should the nurse place in the client's room?
ANS: Suction catheter
RATIONALE: The nurse should place suction equipment in the room of a client who has a
history of seizures. During a seizure, the client might have excessive oral secretions or
might vomit. If the client's airway becomes occluded, then the nurse will need to suction the
oral cavity to maintain a patent airway
• A nurse in a provider's office is reviewing the medical record of a client who
requests a prescription for an oral contraceptive. Which of the following findings
should the nurse identify as a contraindication for oral contraceptive use? ANS:
Coronary artery disease
RATIONALE: Coronary artery disease is a contraindication to oral contraceptive use
because it increases the client's risk for myocardial infarction. Other contraindications for
receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension\
,• A nurse is assisting with the care of a school-age child immediately following
surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction.
Which of the following findings should the nurse report to the provider?
ANS: 250 mL of sanguineous drainage over the last 3 hr
RATIONALE: The nurse should recognize that if more than 3 mL/kg/her of
sanguineous drainage occurs for more than 3 consecutive hours following surgery, it
can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from
the child's chest tube is excessive and the nurse should report this finding to the
provider immediately
• A nurse is collecting data from a client who is at 30 weeks of gestation and has
gestational diabetes. Which of the following findings should the nurse report to
the provider as an indication of hyperglycemia?
ANS: Polyuria
RATIONALE: The nurse should identify polyuria as an expected finding of hyperglycemia
and report this finding to the provider
• A nurse is discussing home safety with a group of clients who have type 1
diabetes mellitus. Which of the following client statements indicates an
understanding of the teaching?
ANS: "I will dispose of my needles in a plastic laundry detergent container."
RATIONALE: The nurse should instruct the client to dispose of needles in a puncture-proof
container, such as a plastic laundry detergent container.
• A nurse is caring for a client who has Alzheimer's disease. Which of the following
actions should the nurse take?
ANS: Encourage the client to reminisce about the past
RATIONALE: The client who has Alzheimer's disease has progressive loss of short-term
memory and might not be able to recall recent happenings and events. This can lead to
increased frustration. However, remote memory remains in place for a longer period of time
and can elicitfeelings of happiness
• A nurse is monitoring a client who is receiving telemetry. Which of the following
ECG findings should the nurse report to the provider?
ANS: PR interval 0.24 seconds
RATIONALE: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval
indicatesa heart block; therefore, the nurse should report this finding provider
• A nurse on a medical unit is reviewing a client's medical record. Which of the
following procedures should the nurse identify requires the client to sign a
separate informed consent form? ANS: Lumbar puncture
RATIONALE: The nurse should identify that a client needs to provide consent for general
treatment, as well as a separate written, informed consent for any treatment that has an
elementof risk, such as a lumbar puncture
,• A licensed practical nurse (LPN) is reviewing client assignments for the upcoming
shift. Which of the following clients should the LPN ask the charge nurse to
reassign to a registered nurse (RN)?
ANS: A client who has a new colostomy and requires the development of a teaching plan
RATIONALE: Developing a client teaching plan is not within the scope of practice for an
LPN.
The nurse should contact the nursing supervisor to inform them of the client's need for a
teaching plan regarding the new colostomy and request that this client is reassigned to an
RN.The scope of practice of an LPN does allow the nurse to reinforce teaching once the
plan has been established
• A nurse is caring for a client who is recovering from a stroke and is experiencing
difficulty using eating utensils. The nurse should identify the need for a referral to
one of the following interprofessional team members?
ANS: Occupational therapist
RATIONALE: The nurse should identify the need for a referral to an occupational therapist to
teachthe client how to use special eating utensils
• A nurse is preparing to perform blood glucose monitoring for a client who has type
1diabetes Mellitus. Which of the following actions should the nurse take first?
ANS: Hold the finger for testing in a dependent position
RATIONALE: Evidence-based practice indicates that the nurse should first position the
testing site to enhance blood flow, which improves the ability to collect an adequate specimen
• A home health nurse is reinforcing teaching with a client about the use of elastic
stockings to decrease peripheral edema. Which of the following instructions
should the nurse include?
ANS: Apply the stockings in the morning
RATIONALE: The nurse should instruct the client to apply the elastic stockings in the
morningand remove them at the end of the day before bedtime
• A nurse in a provider's office is reviewing pediculosis capitis management and
prevention strategies with the parent of a school-age child. Which of the following
strategies should the nurse include? (Select all that apply.)
ANS:
Store the child's clothing in a separate cubicle when at school.
Boil brushes and combs in water for 10 min.
Dry bed linens and clothing in a hot dryer for at least 20 min.
RATIONALE:
Transmission of lice occurs via contact with personal items. Boiling hair care items in hot
water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by
washing in hotdryer for at least 20 min is an appropriate strategy
, • A nurse is contributing to the plan of care for a client who has a continent urinary
diversion. Which of the following interventions should the nurse plan to
implement tofacilitate urinary elimination?
ANS: Use intermittent urinary catheterization for the client on at regular intervals
RATIONALE: A continent urinary diversion contains valves that prevent urine from exiting
the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals
to drainurine from the client's pouch.
• A nurse is preparing to perform a bladder scan for a client. Which of the following
actions should the nurse take?
ANS: Tell the client they should not experience any discomfort
RATIONALE: The nurse applies the handheld scanner over the area of the bladder
when performing a bladder scan. This noninvasive procedure should not cause the
client any discomfort
• A nurse is caring for a client who is crying and states that their provider informed
them that they have a tumor and will need a biopsy. Which of the following
responsesshould the nurse make?
ANS: "What have you done to help yourself get through stressful situations before?"
RATIONALE: This is a therapeutic response. The nurse is aware that the client is under
stress and encourages comparison to investigate whether they have experience dealing
with a stressful situation
• A nurse is caring for a newborn who is 12 hr old. The nurse should expect the
newborn's stool to have which of the following characteristics within the first 24
hourfollowing birth?
ANS: Dark greenish-black and viscous
RATIONALE: The first stool passed by a newborn is the meconium that develops in utero.
It is dark greenish-black and viscous, containing of amniotic fluid, cells, intestinal
secretions, and blood
• A licensed practical nurse is assisting with the preparation of a client for insertion
of a peripherally inserted central venous catheter (PICC). Which of the following
actions should the nurse take?
ANS: Witness the client's signature on the informed consent form.
RATIONALE: The insertion of a PICC is an invasive procedure with risks and benefits.
The nurse should witness the client's signature on the consent form after ensuring the
client has anunderstanding of the procedure, including its risks and benefits
• A nurse is caring for a client who adheres to a kosher diet. Which of the following
food selections should the nurse expect to see on the client's meal tray?