VERSION [QUESTIONS AND ANSWERS] WITH STUDY GUIDE
DETAILED AND VERIFIED FOR GUARANTEED PASS- LATEST
UPDATE 2025 GRADED A
A nurse is preparing to provide tracheostomy care for a client. Which of the
following action should the nurse plan to take? - CORRECT ANSWER Wear
clean gloves while cleaning the inner cannula.
Nurse is caring for a client who has severe rheumatoid arthritis in her hands and
is unable to feed herself. For which of the following healthcare team members
should the nurse request a referral from the provider? - CORRECT ANSWER
Occupational therapist
A nurse is caring for a postoperative client who has an IV PCA delivering opioids.
The client rates the pain as 2 on a scale of 0 to 10 and has not pressed the button
to deliver a bolus dose in over 2 hours. Which of the following action should the
nurse take? - CORRECT ANSWER Instruct the client to push the button more
frequently.
A nurse in a mental health clinic is caring for an older adult client who has
depression and has stopped taking their medication. The client tells the nurse, "I
want to die now that my partner is gone." Which of the following responses
should the nurse make? - CORRECT ANSWER "Have you thought about
harming yourself?"
The nurse is prioritizing care for a client. Which of the following procedures
should the nurse perform first? - CORRECT ANSWER Endotracheal
suctioning.
The nurse manager overhears a nurse telling a client, "I will administer your
medication by injection if you don't swallow your pills." The nurse manager
should identify that the nurse is committing which of the following torts? -
CORRECT ANSWER Assault
The nurse is preparing to administer several medications via an NG tube to a
client who is receiving continuous to feeding. Which of the following action
should the nurse take? - CORRECT ANSWER Dilute each crushed
medication with warm water.
,A nurse he's preparing to provide postmortem care for a client. Which of the
following action should the nurse plan to take? - CORRECT ANSWER Turn
the overhead lights to a bright setting.
A nurse is obtaining a health history from a client. The nurse should recognize
which of the following data as placing the client a higher risk for osteoporosis? -
CORRECT ANSWER The client has a sedentary lifestyle.
A nurse is caring for a client who is postoperative and is in bedrest. Which of the
following action should the nurse take to decrease the clients risk of developing a
pressure injury? - CORRECT ANSWER Ensure the client's heels are not
touching the mattress.
A nurse is preparing to teach a female client about osteoporosis prevention.
Which of the following recommendations should the nurse make for this client? -
CORRECT ANSWER "Walk for 30 minutes 3 to 5 times each week."
The nurse is planning care for a client who has a prescription for extremity
restraints for both wrists. Which of the following action should the nurse include
in the plan of care? - CORRECT ANSWER -Pad bony prominence before
applying to restrains.
-Ensure the client's bed is in the lowest position.
-Assess skin temperature and color before applying the restraints.
Nurses assessing a client who is receiving a blood transfusion. The nurse notes,
lung crackles, hypoxia, and distended neck veins. Which of the following action
should the nurse take? - CORRECT ANSWER -Obtain a prescription for
diuretic.
-Administer oxygen to the client.
-Stop the transfusion.
-Place the client in high-Fowler's position.
A nurse is preparing to reposition a client who has lower back injury. Which of
the following action should the nurse take? - CORRECT ANSWER Flex the
clients knees.
A nurse is providing discharge, teaching about safety considerations to an older
client who lives at home. The client has heart failure and has a new prescription
for hydrochlorothiazide. Which of the following statements by the client indicates
an understanding of the teaching? - CORRECT ANSWER "I will leave a light
on in my bathroom my name."
,A nurse is admitting a client who is at risk for falls to a medical surgical unit.
Which of the following action should the nurse take? - CORRECT ANSWER
Provide the client with a night light.
A nurse is obtaining a health history from a client. Which of the following factors
places the client at risk for cardiovascular disease? - CORRECT ANSWER
Metabolic syndrome.
A nurse is caring for a client who has a terminal illness. The client states, "I am
not giving up. I want as much treatment as possible." Which of the following
responses should the nurse make? - CORRECT ANSWER "I will contact your
provider to discuss your options."
A nurse is preparing to administer packed RBCs to a client who has low
hemoglobin level. Which of the following action should the nurse take prior to the
start of the infusion? - CORRECT ANSWER Check the blood products
compatibility with the client's blood type.
A nurse in an emergency department is caring for a client who is unconscious
and require surgery. There is no one available to give consent for the treatment.
Which of the following action should the nurse take? - CORRECT ANSWER
Prepare the client for surgery
A nurse is teaching a client how to self administer help heparin. Which of the
following instruction should the nurse include in the teaching? - CORRECT
ANSWER Expel air bubble before injecting medication.
A nurse is planning to change a clients tracheostomy ties. Which of the following
action should the nurse take? - CORRECT ANSWER All
A nurse is preparing to perform an Anthropometric assessment on a client.
Which of the following client data should the nurse include? - CORRECT
ANSWER Weight.
A nurse is teaching an older adult client about reducing the risk for osteoporosis.
Which of the following statements by the client indicates an understanding of the
teaching? - CORRECT ANSWER "I will walk three times per week."
A nurse is reviewing a medication prescription that reads "morphine 5 mg IV
bolus for pain." Which of the following components should the nurse clarify with
the provider? - CORRECT ANSWER Time.
A nurse is providing teaching to a client about reducing the adverse effects of
immobility. Which of the following statements by the client indicates an
, understanding of the teaching? - CORRECT ANSWER "I will perform ankle
and knee exercises every hour."
A nurse is caring for a client who has dysphagia when assisting the client during
breakfast. Which of the following actions by the client indicates the nurse should
intervene? - CORRECT ANSWER The client drinks their thickened juice with
a straw.
A nurse is caring for a client who reports frequent headaches and believes
balance is achieved through the concept of Yin and yang. Which of the following
food should a nurse expect the client to choose to treat their headache? -
CORRECT ANSWER Honey.
A home health nurse is assessing the home environment of an older adult who
has osteoporosis. For which of the following findings should the nurse
intervene? - CORRECT ANSWER There's an area rug covering a tile floor.
A nurse is assessing a client who has left sided weakness following a stroke.
Which of the following findings is in the nurses priority? - CORRECT ANSWER
The client coughs frequently while eating.
A nurse is caring for a client who has a colostomy. Which of the following action
should the nurse take? - CORRECT ANSWER Ensure the pouch is 0.32 cm
larger than the stoma.
A nurse is assessing a client who has respecters for developing heart disease.
Which of the following factors does the nurse recognize as modifiable risk
factor? - CORRECT ANSWER Physical inactivity.
A nurse is caring for a client who has left lower lobe atelectasis. In which of the
following positions should the nurse place the client for postural drainage? -
CORRECT ANSWER Side- lying with the right side of the chest elevated.
A nurse is teaching a client about reducing the risk for osteoporosis. Which of
the following statements by the client indicates an understanding of possible
anaphylaxis? - CORRECT ANSWER A sharp decrease in blood pressure.
A nurse is planning care for a client who is immobile. Which of the following
actions should the nurse include in the plan of care? - CORRECT ANSWER
Use trochanter rolls besides the client's legs.
The nurse is reviewing a complementary therapies approved by the provider with
a client who has hypertension. Which of the following supplements should the
nurse discuss with the client? - CORRECT ANSWER Garlic