2025 PRACTICE QUESTIONS AND CORRECT VERIFIED ANSWERS
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A nurse in the emergency department is caring for a client who has abdominal
trauma. Which of the following assessment findings should the nurse identify as
an indication of hypovolemic shock? - CORRECT ANSWER-Tachycardia
Rationale:
Due to the decrease in circulating blood volume that occurs with internal
bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts
to relieve the hypoxia by increasing the heart rate and cardiac output, along with
increasing the respiratory rate.
A nurse is planning to assess the abdomen of a client who reports feeling bloated
for several weeks. Which of the following methods of assessment should the
nurse use first? - CORRECT ANSWER-Inspection
Rationale:
According to evidence-based practice, the nurse should inspect the abdomen first
by observing the contour of the abdomen, the condition of the skin, and the
position of the umbilicus. Findings from this step of assessment are used by the
nurse in the subsequent steps.
,A nurse is responding to a parent's question about his infant's expected physical
development during the first year of life. Which of the following information
should the nurse include? - CORRECT ANSWER-A 10-month-old infant can pull
up to a standing position.
Rationale:
An 8 to 10-month-old infant can pull himself to a standing position.
A nurse is using the I-SBAR communication tool to provide the client's provider
with information about the client. The nurse should convey the client's pain status
in which portion of the report? - CORRECT ANSWER-Assessment
Rationale:
The nurse provides information about assessment findings in this portion of the
report. This includes vital signs, pain assessment, and changes in assessment
findings.
A nurse is providing discharge teaching to a client who is recovering from lung
cancer. The provider instructed the client that he could resume lower-intensity
activities of daily living. Which of the following activities should the nurse
recommend to the client? - CORRECT ANSWER-Washing dishes
Rationale:
Washing dishes requires a low level of activity and is appropriate for this client.
, A client who reports shortness of breath requests her nurse's help in changing
positions. After repositioning the client, which of the following actions should the
nurse take next? - CORRECT ANSWER-Observe the rate, depth, and character of
the client's respirations.
Rationale:
The nurse should apply the nursing process priority-setting framework when
caring for this client. The nurse can use the nursing process to plan client care and
prioritize nursing actions. Each step of the nursing process builds on the previous
step, beginning with assessment or data collection. Before the nurse can
formulate a plan of action, implement a nursing intervention, or notify a provider
of a change in the client's status, the nurse must first collect adequate data from
the client. Assessing or collecting additional data will provide the nurse with
knowledge to make an appropriate decision; therefore, the first action the nurse
should take is to assess the client's respiratory status.
A nurse is planning to insert a nasogastric tube for a client after explaining the
procedure. The client states, "You are not putting that hose down my throat."
Which of the following statements should the nurse make? - CORRECT
ANSWER-"I can see that this is upsetting you."
Rationale:
The nurse is using the therapeutic communication techniques of reflecting and
restating, which encourages communication by the client.
An assistive personnel (AP) is assisting a nurse with the care of a female client
who has an indwelling urinary catheter. Which of the following actions by the AP