ANSWERS : {LATEST 2025/ 2026 UPDATE} COMPLETE REAL AND
AUTHENTIC EXAM {100% CORRECT} RATED A+!!!!
Which position would the nurse plan to use for the client who is having a
hypertensive crisis and evolving stroke?
A. Supine
B. Side-lying
C. Orthopneic
D. Trendelenburg -
E. Answer-ANS: B
Side-lying
Rationale:
The side-lying position will neither raise intracranial pressure nor interfere with
respirations and will permit oral secretions to drain from the mouth by gravity.
A- The supine position can compromise the airway by permitting the tongue to fall to the
posterior pharynx and obstruct the airway.
C- The orthopneic position may place pressure on the brainstem.
D- The Trendelenburg position is contraindicated because it may increase intracranial
pressure.
Which topic will the nurse include in teaching for a client with Raynaud disease?
A. Tobacco avoidance
B. Dietary salt reduction
C. Need for increased exercise
D. Low-fat, low-cholesterol diet -
E. Answer-ANS: A
Tobacco avoidance
Rationale:
The symptoms of Raynaud disease are caused by sudden arterial vasoconstriction and
tobacco use also causes arterial vasoconstriction, which will worsen symptoms.
,B- Dietary salt is not a factor in causing the sudden arterial spasm that leads to the
symptoms of Raynaud disease.
C- There is no indication for increased exercise in Raynaud disease, although the nurse
will teach the client to avoid exercising in cold temperatures.
D- Raynaud disease is not caused by atherosclerosis, and a low-fat, low-cholesterol diet
will not help prevent symptoms.
When teaching a client who has a new diagnosis of Raynaud disease, which
information will the nurse include? Select all that apply.
A. Medications will be needed to control the symptoms.
B. Stop cigarette smoking and other tobacco use.
C. Wear gloves when getting food from the freezer.
D. Plan to take a daily low-dose aspirin tablet.
E. Avoid going quickly from a warm to a cold environment. -
F. Answer-ANS: B, C, E
Rationale:
Tobacco use increases the vasospasm that causes Raynaud disease symptoms. Use of
gloves when handling cold foods helps prevent triggering of vasospasm in the fingers.
Moving quickly from a warm to a cold environment may trigger vasospasm and cause
symptoms.
A- Medications such as calcium channel blockers are only used after lifestyle changes
are unsuccessful in relieving symptoms.
D- Low-dose aspirin is not used for treatment of Raynaud disease.
A child with pulmonary edema is treated with opioids and furosemide. Which
nursing interventions would the nurse perform to promote safe medication
administration?
Select all that apply.
A. Following the principle of atraumatic care
B. Administering oral drugs with food or snacks
C. Documenting the client's age, weight, and height
D. Exposing the child to sunlight for healthy growth
, E. Administering medications if the client reports dizziness or drowsiness -
F. Answer-ANS: A, B, C
Rationale:
A local anesthetic should be applied at the injection site to promote atraumatic care.
Administering drugs with food reduces gastric discomfort. The client's afe, weight, and
height should be documented to help ensure correct calculation of the medication dose.
D- A child who is undergoing treatment with diuretics should not be exposed to sunlight
because this can cause fluid volume loss and exhaustion.
E- If the client reports dizziness or drowsiness, medications should not be administered
until a prescription is prescribed by the primary health care provider.
Which would the nurse do to help alleviate the distress of a client with heart
failure and pulmonary edema?
A. Encourage frequent coughing.
B. Elevate the client's lower extremities.
C. Prepare for modified postural drainage.
D. Place the client in the orthopneic position. -
E. Answer-ANS: D
Place the client in the orthopneic position.
Rationale:
The orthopneic, or tripod position, allows maximum lung expansion because gravity
reduces the pressure of the abdominal viscera on the diaphragm and lungs.
A- Coughing is useful for clients who have excessive mucus in the airways, such as
clients with pneumonia, but is not useful for clearing pulmonary edema.
B- Elevation of the extremities should be prevented because it increases venous return,
placing an increased workload on the heart.
C- Positioning for postural drainage does not relieve acute dyspnea; furthermore, it
increases venous return to the heart.
A client who has been admitted with pulmonary edema and received furosemide
intravenously needs to void. Which action by the nurse would be best?
A. Place the client on a bedpan.
B. Use adult diapers for the client.