ACTUAL EXAM COMPLETE 200 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) ALREADY GRADED A+ BRAND
NEW!!
1. A male client with stomach cancer returns to the unit
following a total gastrectomy. He has a nasogastric tube to
suction and is receiving Lactated Ringer's solution at 75
mL/hour IV. One hour after admission to the unit, the
nurse notes 300 mL of blood in the suction canister, the
client's heart rate is 155 beats/minute, and his blood
pressure is 78/48 mmHg. In addition to reporting the
finding to the surgeon. Which action should the nurse
implement first? - ANSWER >>>>d. Increase the infusion
rate of Lactated Ringer's solution.
2. an adult male who fell 20 feet from the roof of this home
has multiple injuries, including a right pneumothorax.
Chest tubes were inserted in the emergency department
prior to his transfer to the intensive care unit (ICU). the
nurse notes that the suction control chamber is bubbling at
the
- 10 cm H2O mark, with fluctuation in the water seal, and
over the past hour 75 ml of bright red blood is measured in
the collection chamber. Which intervention should the
,nurse implement? - ANSWER >>>>a. Add sterile water to
the suction control chamber.
3. A client who received hemodialysis yesterday is
experiencing a blood pressure of 200/100 mmHg, heart
rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of
breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should the
nurse take first? - ANSWER >>>>c. Begin supplemental
oxygen.
4. A client with Addison's crisis is admitted for treatment
with adrenal cortical supplementation. Based on the
client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply) -
ANSWER >>>>Headache and tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and
dehydration. Which assessment finding is the best
indicator of hydration that the nurse should report to the
healthcare provider? - ANSWER >>>>d. Skin tenting
occurs when the client's forearm is pinched.
6. After an inservice about electronic health record (EHR)
security and safeguarding client information, the nurse
observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should
,the nurse take? - ANSWER >>>>a. File a detailed incident
report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program
for clients with cardiovascular disease implemented in a
rural health clinic. Which outcome indicate the program is
effective? - ANSWER >>>>c. Clients who incurred
disease complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic obstructive
pulmonary disease (COPD) who uses oxygen at 2
L/minute per nasal cannula continuously. The nurse
observes that the client is having increased shortness of
breath with respirations at 23 breaths/minute. Which
action should the nurse implement first? - ANSWER
>>>>d. Assess the delivery mechanism of the oxygen
tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-
subtotal thyroidectomy requires an immediate
investigation by the nurse? - ANSWER >>>>When I get
out of bed quickly, I feel a little dizzy."
10. An older adult male who is in his early 70's is admitted
to the emergency department because of a COPD
exacerbation. This client is struggling to breathe and the
healthcare team is preparing for endotracheal intubation.
The spouse's wife, who is 30 years younger than the
client, asks the nurse to stop the procedure and provide
the nurse a copy of the client's living will. Which action
, should the nurse take? - ANSWER >>>>b. Notify the
healthcare provider of the client's wishes.
11. An unlicensed assistive personnel (UAP) is assigned
to provide personal care for a client whose prescribed
activity is bedrest with bedside commode use. The UAP
reports to the nurse that the client is so obese that the
UAP feels unable to safely assist the client in transferring
from the bed to the bedside commode. How should the
nurse respond? - ANSWER >>>>c. Advice the client to
maintain bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the
students at a middle school are overweight. The nurse
presents the information at the parent-teacher meeting.
What action is most important for the nurse to include in
the meeting? - ANSWER >>>>c. Distribute a shopping list
of suggested healthy snack items.
13. After several months of chronic fatigue, morning
stiffness, and join pain, a young adult is diagnosed with
rheumatoid arthritis, and the healthcare provider
prescribes prednisone. Which education should the nurse
provide the client with regard to taking prednisone? -
ANSWER >>>>c. If sequential doses are missed, notify
the healthcare provider.
14. The psychiatric nurse is caring for clients on an
adolescent unit. Which client requires the nurse's
immediate attention? - ANSWER >>>>c. An 18-year-old