C WITH QUESTIONS AND CORRECT ANSWERS
CURRENTLY TESTED AND APPROVED NEW
MODIFIED 2025/2026 LATEST WITH RATIONALES
• A nurse is contributing to the plan of care for a client who is receiving continuous
bladder irrigation following a transurethral resection of the prostate (TURP). Which of the
following interventions should the nurse include?
ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color
RATIONALE: The nurse should maintain the flow rate of the bladder irrigation to keep the
urine diluted to a reddish-pink color and the tubing free of clots and bleeding
• A nurse is assisting with the care of a client who is postpartum and has a deep-vein
thrombosis. The client has been receiving heparin IV infusion. Which of the following
medications should the nurse ensure is readily available?
ANS: Protamine sulfate
RATIONALE: The nurse should ensure that protamine sulfate is readily available. Protamine
sulfate is the antidote used to reverse the anticoagulant effects of heparin
• A nurse is reinforcing teaching with a client about how to replace their two piece
ostomy pouching system. The client tells the nurse that removing the skin barrier is painful.
Which of the following strategies should the nurse suggest?
ANS: Hold the skin taut while removing the barrier
RATIONALE: Gently and gradually peeling the skin barrier away while holding the skin taut
minimizes discomfort and trauma to the peristomal skin
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,• A nurse in an inpatient mental health facility is caring for a newly admitted client who
has alcohol use disorder. During a therapy session, the client asks about Alcoholics
Anonymous (AA). Which of the following responses should the nurse make?
ANS: "What is your current understanding about the purpose of AA?" RATIONALE: The
nurse should identify the client's understanding about the purpose ofAA to provide further
information about the program and meetings and to facilitate a referral if needed. For
treatment to be successful, the nurse should involve the client in the care decision-making
process. This ensures the treatment program meets the client's individual needs and
demonstrates caring by the nurse
• A nurse is performing a dressing change for a client who is 3 days postoperative.
Which Of the following findings should the nurse report to the provider?
ANS: Yellow-green drainage at the incision line
RATIONALE: Yellow-green, purulent, or odorous drainage indicates the wound is infected.
The nurse should report this finding to the Provider
• A nurse is providing comfort to the partner of a client who has died. Which of the
following statements should the nurse make?
ANS: "Journaling about your relationship might help with the grieving process."
RATIONALE: Journaling provides a means for the client to identify thoughts and feelings
and to recognize and come to terms with the positive and negative aspects the client's
relationship with their partner
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,• A nurse is assisting with an educational session for newly licensed nurses about
partner violence. Which of the following characteristics should the Nurse included as placing
a vulnerable person at risk for partner violence? ANS: Recent confirmation of pregnancy
RATIONALE: The nurse should include pregnancy as a characteristic placing a vulnerable
person at risk for partner violence. The perpetrator might view the pregnancy as a threat to
the relationship due to the attention the child receives
• A nurse is reviewing the techniques for transferring a client from a bed toa chair with
a group of assistive personnel (AP). Which of the following instructions should the nurse
include?
ANS: Use lower-body strength
RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a
client to reduce stress on the back
• A nurse is participating in a quality improvement study about the effectiveness of
client pain management in the unit. Which of the following strategies should the nurse use to
collect data?
ANS: Review clients' charts for their rating of pain before pain medication was administered
and 1 hr after administration
RATIONALE: The nurse should collect data from clients' charts about pain ratings before
and after pain management interventions
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, • A nurse is reinforcing teaching about confidentiality with a client who has a new
diagnosis of HIV. Which of the following information should the nurse include in the
teaching?
ANS: "Your HIV status will be shared with members of your health care team."
RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare
team who provides direct care for the client, just like any other diagnoses
• A nurse is planning care for a client who has a history of seizures. Which of the
following pieces of equipment should the nurse place in the client's room?
ANS: Suction catheter
RATIONALE: The nurse should place suction equipment in the room of a client who has a
history of seizures. During a seizure, the client might have excessive oral secretions or might
vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral
cavity to maintain a patent airway
• A nurse in a provider's office is reviewing the medical record of a client who requests
a prescription for an oral contraceptive. Which of the following findings should the nurse
identify as a contraindication for oral contraceptive use?
ANS: Coronary artery disease
RATIONALE: Coronary artery disease is a contraindication to oral contraceptive use because
it increases the client's risk for myocardial infarction. Other contraindications for receiving
oral contraceptives include gallbladder disease, breast cancer, and hypertension\
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