Tested and Verified Updated Complete
Solutions 2025
A,.nurse,.is,.assessing,.the,.heart,.sounds,.of,.a,.client,.who,.has,.developed,.ch
est,.pain,.that,.becomes,.worse,.with,.inspiration.
The,.nurse,.auscultates,.a,.high-
pitched,.scratching,.sound,.during,.both,.systole,.and,.diastole,.with,.the,.diap
hragm,.of,.the,.stethoscope,.positioned,.at,.the,.left,.sternal,.border.
Which, . of, . the,. following, . heart,. sounds, . should, . the,. nurse, . document?
A. Audible, . Click
B. Murmur
C. Third,.heart,.sound
D. Pericardial, . friction, . rub, . -Correct, . Answer=, . D), . Pericardial, . friction, . rub
A,.nurse,.is,.obtaining,.the,.blood,.pressure,.in,.a,.client's,.lower,.
extremity.,.Which,.of,.the,.following,.action,.should,.the,.nurse,.t
ake?
A. Auscultate,. for,. the,. blood,. pressure,. at,. the,. dorsalis,. pedis,. artery.
B. Measure,. the,. blood,.pressure,.with,.the,.client,.sitting,. on,. the,.side,.of,.the,.b
ed.
C. Place, . the, . cuff, . 7.6cm, . (3in), . above, . the, . popliteal, . artery.
D. Place,.the,.bladder,.of,.the,.cuff,.over,.the,.posterior,.aspect,.of,.the,.t
high.,.-
,.Correct,.Answer=,.D),.place,.the,.bladder,.of,.the,.cuff,.over,.the,.posteri
or,.aspect,.of,.the,.thigh
,A,.charge,.nurse,.is,.teaching,.adult,.cardiopulmonary,.resuscitation,.(CPR),.to,.
a,.group,.of,.newly,.licensed,.nurses.
Which,.of,.the,.following,.actions,.should,.the,.charge,.nurse,.teach,.as,.the,.first
,.response,.in,.CPR?
A. Call,.for,.assistance
B. Begin,.Chest,. compressions
C. Confirm,.unresponsiveness.
D. Give,.rescue,.breaths.,.-Correct,.Answer=,.C),.Confirm,.unresponsiveness
,A,.nurse,.is,.caring,.for,.a,.client,.who,.requires,.a,.chest,.x-ray.
Prior,.to,.the,.client,.being,.transported,.for,.the,.procedure,,.which,.of,.the,.foll
owing,.actions,.should,.the,.nurse,.take,.first?
A. Explain,.the,. x-ray,. procedure,.to,. the,.client.
B. Help,.the,.client,.into,.a,.wheelchair,.before,.the,.transporter,.arrives.
C. Ask,.if,.the,. client,.has,.any,. questions.
D. Identify, . the, . client, . using, . two, . identifiers., . -
Correct, . Answer=, . D), . Identify,.the, . client,.using,.to,.identifiers
A,.nurse,.is,.caring,.for,.a,.child,.who,.is,.postoperative,.following,.a,.tonsi
llectomy.,.Which,. of,.the,.following,.actions,.should,.the,.nurse,.take?
A. Encourage,.the,.child,.to,.cough,.frequently,.to,.clear,.congestion,.fr
om,.anesthesia.
B. Place,.a,. heating,. pad,. at,. the,. child's,. neck,. for,. comfort.
C. Administer,.analgesics,.to,.the,.child,.on,.a,.routine,.schedule,.throughout,.
the,.day,.and,.night.
D. Provide,.the,.child,.with,.ice,.cream,.when,.oral,.intake,.is,.initiated.,.-
Correct,.Answer=,.C),.Administer,.analgesics,.to, . the,.child,.on,.a,.routine,.
schedule,.throughout,.the,.day,.and, . night
A,.nurse,.is,.providing,.teaching,.to,.a,.client,.who,.has,.heart,.failure,.about,.ho
w,.to,.reduce,.his,.daily,.intake,.of,.sodium.
Which,.of,.the,.following,.factors,.is,.the,.most,.important,.in,.determinin
g,.the,.client's,.ability,.to,.learn,.new,.dietary,.habits?
A. The,.involvement,.of,.the,.client,.in,.planning,.the,.change.
B. The,.emphasis,.the,.provider,.places,.on,.the,.dietary,.changes.
C. The,. learning,. theory,. the,. nurse,. uses,. to,. teach,. the,. dietary, . changes.
D. The,.extent,.of,.the,.dietary,.changes,.planned,.for,.the,.client.,.-
Correct,.Answer=, . A),.The,.involvement,.of, . the,.client,.in,.planning,.t
he, . change
, A,.charge,.nurse,.is,.observing,.a,.newly,.licensed,.nurse,.perform,.tracheosto
my,.care,.for,.a,.client.
Which,.of,.the,.following,.actions,.by,.the,.newly,.licensed,.nurse,.requires,.inter
vention?
A. Obtaining, . hydrogen, . peroxide, . for, . the, . tracheostomy, . care.
B. Obtaining,. cotton, . balls,.for,. the,. tracheostomy,. care.
C. Obtaining, . sterile, . gloves, . for, . the, . tracheostomy, . care.
D. Obtaining,.a,.sterile,.brush,.for,.the,.tracheostomy,.care.,.-
Correct,.Answer=,.B),.Obtaining,.cotton,.balls,.for,.the,.tracheo
stomy
A,.nurse,.is,.preparing,.to,.perform,.mouth,.care,.for,.an,.unresponsive
,.client.,.Which,.of,.the,.following,.actions,.should,.the,.nurse,.plan,.t
o,.take?
A. Place,.the,.client,.supine.
B. Keep,. both,.side,. rails,.up.
C. Raise,.the,.level,.of,.the,.bed.
D. Inspect,.the,.client's,.mouth,.using,.a,.finger,.sweep.,.-
Correct,.Answer=,.C),.Raise,.the,.level,.of,.the,.bed
A,.nurse,.is,.witnessing,.a,.client,.sign,.an,.informed,.consent,.form,.for
,.surgery.,.Which,.of,.the,.following,.describes,.what,.the,.nurse,.is,.affirm
ing,.by,.this,.action?
A. The,. client,. fully,. understands,. the,. provider's,. explanation,. of,. the,. procedure.
B. The,.client,.has,.been,.informed,.about,.the,.risks,.and,.benefits,.of
,.the,.procedure.
C. The, . nurse, . witnessed, . the, . provider's, . explanation, . of, . the, . procedure.
D. The,.signature,.on,.the,.preoperative,.consent,.form,.is,.the,.client's.,.-
Correct,.Answer=
D),. The,. signature,. on,. the,. pre-operative,. consent,. form, . is,. the,. clients