LATEST 2024/2025 QUESTIONS AND VERIFIED CORRECT
ANSWERS/ALREADY GRADED A++
A nurse is reviewing the medical record of a client who has schizophrenia
and is taking clozapine. Which of the following findings should the nurse
identify as a contraindication to the administration of clozapine?
A. HR 58
B. Fasting blood glucose 100
C. Hgb 14
D. WBC 2900 - ANSWER D. WBC 2900
A nurse is developing an in service about personality disorders. Which of
the following information should the nurse include when discussing
borderline personality disorder?
A. The clients exhibits impulse behavior
B. The client might act seductively
C. The client is exceptionally clingy to others
D. The client is overly concerned about minor details - ANSWER A. The
clients exhibits impulse behavior
Intra-dermal Injections areas.
A. Buttocks
B. Upper back
C. Hamstring - ANSWER B. Upper back
A nurse is caring for a client who has experienced a right-hemispheric
stroke. Which of the following are expected findings? SATA
A. Impulse control difficulty
B. Left Hemiplegia
C. Loss of depth perception
D. Aphasia
E. Lack of situational awareness - ANSWER A. Impulse control difficulty
B. Left Hemiplegia
C. Loss of depth perception
E. Lack of situational awareness
,A nurse is caring for a client who has global aphasia (both receptive and
expressive.). Which of the following should the nurse include in the client's
plan of care? SATA
A. Speak to the client at a slower rate
B. Assist the client to use flash card with pictures
C. Speak to the client in a loud voice.
D. Complete sentences that the client cannot finish.
E. Give instructions one step at a time - ANSWER A. Speak to the client at
a slower rate
B. Assist the client to use flash card with pictures
E. Give instructions one step at a time
A nurse is assessing a client who has experienced a left-hemispheric
stroke. Which of the following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception - ANSWER C. Inability to recognize familiar
objects
A nurse is reviewing ABG laboratory results of a client who is in respiratory
distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg.
The nurse should recognize that the client is experiencing which of the
following acid-base imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - ANSWER B. Respiratory alkalosis
A nurse is caring for a client following a thoracentesis. Which of the
following manifestations should the nurse recognize as risks for
complications? SATA
A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the puncture site - ANSWER A. Dyspnea
C. Fever
D. Hypotension
,A nurse is preparing to care for a client following chest tube placement.
Which of the following items should be available in the client's room? SATA
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - ANSWER A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
E. Occlusive dressing
A nurse is assessing a client who has a chest tube and drainage system in
place. Which of the following are expected findings? SATA
A. Gentle Constant bubbling in the suction control chamber
B. Rise and fall in the level of water in the water seal chamber with
inspiration and expiration
C. Exposed sutures without dressing.
D. Drainage system upright at chest level - ANSWER A. Gentle Constant
bubbling in the suction control chamber
B. Rise and fall in the level of water in the water seal chamber with
inspiration and expiration
A nurse is planning care for a client following the insertion of a chest tube
and drainage system. Which of the following should be included in the plan
of care? SATA
A. Encourage the client to cough every 2 hours
B. Check the continuous bubbling in th suction chamber
C. Strip the drainage tubing every 4 hours.
D. Clamp the tube once a day.
E. Obtain a chest x-ray - ANSWER A. Encourage the client to cough every
2 hours
B. Check the continuous bubbling in th suction chamber
E. Obtain a chest x-ray
A nurse is orientation a newly licensed nurse who is caring for a client who
is receiving mechanical ventilation and is receiving mechanical ventilation
and is on pressure support ventilation (PSV) mode. Which of the following
statements by the newly licensed nurse indicates and understanding of
PSV?
A. "It keeps the alveoli open and prevents atelectasis."
, B. "It allows preset pressure delivered during spontaneous ventilation."
C. "It guarantees minimal minute ventilator.
D. "It delivers a preset ventilatory rate and tidal volume to the client." -
ANSWER B. "It allows preset pressure delivered during spontaneous
ventilation."
A nurse is caring for a client who is experiencing respiratory distress.
Which of the following early manifestations of hypoxemia should the nurse
recognize? SATA
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevation blood pressure. - ANSWER B. Pale skin
E. Elevation blood pressure.
A nurse is orienting a newly licensed nurse on performing routine
assessment of a client who is receiving mechanical ventilation via an
endotracheal tube. Which of the following information should the nurse
include in the teaching?
A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings ever 8 hours.
C. Document tube placement in centimeters at the angle of jaw.
D. Assess breath sounds every 1 to 2 hours. - ANSWER D. Assess breath
sounds every 1 to 2 hours.
A nurse is caring for a client who has dyspnea and will receive oxygen
continuously. Which of the following oxygen devices should the nurse use
to deliver a precise amount of oxygen to the client?
A. Non rebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask - ANSWER B. Venturi mask
A nurse is planning care for a client who is receiving mechanical ventilation.
Which of the following modes of ventilation that increase the effort of the
client's respiratory muscles should the nurse include in the plan of care?
SATA
A. Assist-control
B. SIMV