Answers 2024-2025 graded A+
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Urinary ,.catheterization ,.is ,.prescribed ,.for ,.a ,.postoperative ,.female ,.client ,.who ,.has ,.been ,.unable ,.to
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,.void ,.for ,.8 ,.hours. ,.The ,.nurse ,.inserts ,.the ,.catheter, ,.but ,.no ,.urine ,.is ,.seen ,.in ,.the ,.tubing. ,.Which
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,.action ,.will ,.the ,.nurse ,.take ,.next?
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A. ,.Clamp ,.the ,.catheter ,.and ,.recheck ,.it ,.in ,.60 ,.minutes.
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B. ,.Pull ,.the ,.catheter ,.back ,.3 ,.inches ,.and ,.redirect ,.upward.
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C. ,.Leave ,.the ,.catheter ,.in ,.place ,.and ,.reattempt ,.with ,.another ,.catheter.
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D. ,.Notify ,.the ,.health ,.care ,.provider ,.of ,.a ,.possible ,.obstruction. ,.- ,.(correct ,.answer) ,.-Answer: ,.C
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It ,.is ,.likely ,.that ,.the ,.first ,.catheter ,.is ,.in ,.the ,.vagina, ,.rather ,.than ,.the ,.bladder. ,.Leaving ,.the ,.first
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g,.catheter ,.in ,.place ,.will ,.help ,.locate ,.the ,.meatus ,.when ,.attempting ,.the ,.second ,.catheterization ,.(C).
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g,.The ,.client ,.should ,.have ,.at ,.least ,.240 ,.mL ,.of ,.urine ,.after ,.8 ,.hours. ,.(A) ,.does ,.not ,.resolve ,.the
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g,.problem. ,.(B) ,.will ,.not ,.change ,.the ,.location ,.of ,.the ,.catheter ,.unless ,.it ,.is ,.completely ,.removed, ,.in
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g,.which ,.case ,.a ,.new ,.catheter ,.must ,.be ,.used. ,.There ,.is ,.no ,.evidence ,.of ,.a ,.urinary ,.tract ,.obstruction
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g,.if ,.the ,.catheter ,.could ,.be ,.easily ,.inserted ,.(D).
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The ,.nurse ,.is ,.teaching ,.an ,.obese ,.client, ,.newly ,.diagnosed ,.with ,.arteriosclerosis, ,.about ,.reducing
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,.the ,.risk ,.of ,.a ,.heart ,.attack ,.or ,.stroke. ,.Which ,.health ,.promotion ,.brochure ,.is ,.most ,.important ,.for
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,.the ,.nurse ,.to ,.provide ,.to ,.this ,.client?
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A. ,."Monitoring ,.Your ,.Blood ,.Pressure ,.at ,.Home"
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B. ,."Smoking ,.Cessation ,.as ,.a ,.Lifelong ,.Commitment"
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C. ,."Decreasing ,.Cholesterol ,.Levels ,.Through ,.Diet"
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D. ,."Stress ,.Management ,.for ,.a ,.Healthier ,.You" ,.- ,.(correct ,.answer) ,.-Answer: ,.C
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A ,.health ,.promotion ,.brochure ,.about ,.decreasing ,.cholesterol ,.(C) ,.is ,.most ,.important ,.to ,.provide ,.this
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,.client, ,.because ,.the ,.most ,.significant ,.risk ,.factor ,.contributing ,.to ,.development ,.of ,.arteriosclerosis
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,.is ,.excess ,.dietary ,.fat, ,.particularly ,.saturated ,.fat ,.and ,.cholesterol. ,.(A) ,.does ,.not ,.address ,.the
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,.underlying ,.causes ,.of ,.arteriosclerosis. ,.(B ,.and ,.D) ,.are ,.also ,.important ,.factors ,.for ,.reversing
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,.arteriosclerosis ,.but ,.are ,.not ,.as ,.important ,.as ,.lowering ,.cholesterol ,.(C).
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,Ten ,.minutes ,.after ,.signing ,.an ,.operative ,.permit ,.for ,.a ,.fractured ,.hip, ,.an ,.older ,.client ,.states, ,."The
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,.aliens ,.will ,.be ,.coming ,.to ,.get ,.me ,.soon!" ,.and ,.falls ,.asleep. ,.Which ,.action ,.should ,.the ,.nurse
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,.implement ,.next?
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A. ,.Make ,.the ,.client ,.comfortable ,.and ,.allow ,.the ,.client ,.to ,.sleep.
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B. ,.Assess ,.the ,.client's ,.neurologic ,.status.
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C. ,.Notify ,.the ,.surgeon ,.about ,.the ,.comment.
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D. ,.Ask ,.the ,.client's ,.family ,.to ,.co-sign ,.the ,.operative ,.permit. ,.- ,.(correct ,.answer) ,.-Answer: ,.B
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This ,.statement ,.may ,.indicate ,.that ,.the ,.client ,.is ,.confused. ,.Informed ,.consent ,.must ,.be ,.provided ,.by
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,.a ,.mentally ,.competent ,.individual, ,.so ,.the ,.nurse ,.should ,.further ,.assess ,.the ,.client's ,.neurologic
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,.status ,.(B) ,.to ,.be ,.sure ,.that ,.the ,.client ,.understands ,.and ,.can ,.legally ,.provide ,.consent ,.for ,.surgery.
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,.(A) ,.does ,.not ,.provide ,.sufficient ,.follow-up. ,.If ,.the ,.nurse ,.determines ,.that ,.the ,.client ,.is ,.confused,
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,.the ,.surgeon ,.must ,.be ,.notified ,.(C) ,.and ,.permission ,.obtained ,.from ,.the ,.next ,.of ,.kin ,.(D).
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The ,.nurse-manager ,.of ,.a ,.skilled ,.nursing ,.(chronic ,.care) ,.unit ,.is ,.instructing ,.UAPs ,.on ,.ways ,.to
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,.prevent ,.complications ,.of ,.immobility. ,.Which ,.intervention ,.should ,.be ,.included ,.in ,.this ,.instruction?
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A. ,.Perform ,.range-of-motion ,.exercises ,.to ,.prevent ,.contractures.
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B. ,.Decrease ,.the ,.client's ,.fluid ,.intake ,.to ,.prevent ,.diarrhea.
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C. ,.Massage ,.the ,.client's ,.legs ,.to ,.reduce ,.embolism ,.occurrence.
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D. ,.Turn ,.the ,.client ,.from ,.side ,.to ,.back ,.every ,.shift. ,.- ,.(correct ,.answer) ,.-Answer: ,.A
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Performing ,.range-of-motion ,.exercises ,.(A) ,.is ,.beneficial ,.in ,.reducing ,.contractures ,.around ,.joints. ,.(B,
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,.C, ,.and ,.D) ,.are ,.all ,.potentially ,.harmful ,.practices ,.that ,.place ,.the ,.immobile ,.client ,.at ,.risk ,.of
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,.complications.
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The ,.nurse ,.is ,.assisting ,.a ,.client ,.to ,.the ,.bathroom. ,.When ,.the ,.client ,.is ,.5 ,.feet ,.from ,.the ,.bathroom
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,.door, ,.he ,.states, ,."I ,.feel ,.faint." ,.Before ,.the ,.nurse ,.can ,.get ,.the ,.client ,.to ,.a ,.chair, ,.the ,.client ,.starts
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,.to ,.fall. ,.Which ,.is ,.the ,.priority ,.action ,.for ,.the ,.nurse ,.to ,.take?
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A. ,.Check ,.the ,.client's ,.carotid ,.pulse.
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B. ,.Encourage ,.the ,.client ,.to ,.get ,.to ,.the ,.toilet.
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C. ,.In ,.a ,.loud ,.voice, ,.call ,.for ,.help.
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D. ,.Gently ,.lower ,.the ,.client ,.to ,.the ,.floor. ,.- ,.(correct ,.answer) ,.-Answer: ,.D
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(D) ,.is ,.the ,.most ,.prudent ,.intervention ,.and ,.is ,.the ,.priority ,.nursing ,.action ,.to ,.prevent ,.injury ,.to ,.the
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,.client ,.and ,.the ,.nurse. ,.Lowering ,.the ,.client ,.to ,.the ,.floor ,.should ,.be ,.done ,.when ,.the ,.client ,.cannot
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,.support ,.his ,.own ,.weight. ,.The ,.client ,.should ,.be ,.placed ,.in ,.a ,.bed ,.or ,.chair ,.only ,.when ,.sufficient
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, g ,.help ,.is ,.available ,.to ,.prevent ,.injury. ,.(A) ,.is ,.important ,.but ,.should ,.be ,.done ,.after ,.the ,.client ,.is ,.in
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g ,.a ,.safe ,.position. ,.Because ,.the ,.client ,.is ,.not ,.supporting ,.himself, ,.(B) ,.is ,.impractical. ,.(C) ,.is ,.likely ,.to
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g ,.cause ,.chaos ,.on ,.the ,.unit ,.and ,.might ,.alarm ,.the ,.other ,.clients.
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A ,.female ,.nurse ,.is ,.assigned ,.to ,.care ,.for ,.a ,.close ,.friend, ,.who ,.says, ,."I ,.am ,.worried ,.that ,.friends
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,.will ,.find ,.out ,.about ,.my ,.diagnosis." ,.The ,.nurse ,.tells ,.her ,.friend ,.that ,.legally ,.she ,.must ,.protect ,.a
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,.client's ,.confidentiality. ,.Which ,.resource ,.describes ,.the ,.nurse's ,.legal ,.responsibilities?
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A. ,.Code ,.of ,.Ethics ,.for ,.Nurses
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B. ,.State ,.Nurse ,.Practice ,.Act
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C. ,.Patient's ,.Bill ,.of ,.Rights
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D. ,.ANA ,.Standards ,.of ,.Practice ,.- ,.(correct ,.answer) ,.-Answer: ,.B
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The ,.State ,.Nurse ,.Practice ,.Act ,.(B) ,.contains ,.legal ,.requirements ,.for ,.the ,.protection ,.of ,.client
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,.confidentiality ,.and ,.the ,.consequences ,.for ,.breaches ,.in ,.confidentiality. ,.(A) ,.outlines ,.ethical
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,.standards ,.for ,.nursing ,.care ,.but ,.does ,.not ,.include ,.legal ,.guidelines. ,.(C ,.and ,.D) ,.describe
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,.expectations ,.for ,.nursing ,.practice ,.but ,.do ,.not ,.address ,.legal ,.implications.
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The ,.nurse ,.is ,.teaching ,.a ,.client ,.how ,.to ,.perform ,.progressive ,.muscle ,.relaxation ,.techniques ,.to
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,.relieve ,.insomnia. ,.A ,.week ,.later ,.the ,.client ,.reports ,.that ,.he ,.is ,.still ,.unable ,.to ,.sleep, ,.despite
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,.following ,.the ,.same ,.routine ,.every ,.night. ,.Which ,.action ,.should ,.the ,.nurse ,.take ,.first?
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A. ,.Instruct ,.the ,.client ,.to ,.add ,.regular ,.exercise ,.as ,.a ,.daily ,.routine.
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B. ,.Determine ,.if ,.the ,.client ,.has ,.been ,.keeping ,.a ,.sleep ,.diary.
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C. ,.Encourage ,.the ,.client ,.to ,.continue ,.the ,.routine ,.until ,.sleep ,.is ,.achieved.
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D. ,.Ask ,.the ,.client ,.to ,.describe ,.the ,.routine ,.that ,.the ,.client ,.is ,.currently ,.following. ,.- ,.(correct
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,.answer) ,.-Answer: ,.D
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The ,.nurse ,.should ,.first ,.evaluate ,.whether ,.the ,.client ,.has ,.been ,.adhering ,.to ,.the ,.original
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,.instructions ,.(D). ,.A ,.verbal ,.report ,.of ,.the ,.client's ,.routine ,.will ,.provide ,.more ,.specific ,.information
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,.than ,.the ,.client's ,.written ,.diary ,.(B). ,.The ,.nurse ,.can ,.then ,.determine ,.which ,.changes ,.need ,.to ,.be
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,.made ,.(A). ,.The ,.routine ,.practiced ,.by ,.the ,.client ,.is ,.clearly ,.unsuccessful, ,.so ,.encouragement ,.alone
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,.is ,.insufficient ,.(C).
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A ,.65-year-old ,.client ,.who ,.attends ,.an ,.adult ,.daycare ,.program ,.and ,.is ,.wheelchair-mobile ,.has
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,.redness ,.in ,.the ,.sacral ,.area. ,.Which ,.instruction ,.is ,.most ,.important ,.for ,.the ,.nurse ,.to ,.provide?
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A. ,.Take ,.a ,.vitamin ,.supplement ,.tablet ,.once ,.a ,.day.
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B. ,.Change ,.positions ,.in ,.the ,.chair ,.at ,.least ,.every ,.hour.
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