and Answers (2026) | Updated Comprehensive
Review with Detailed Rationales | A+ Verified
• A client with chronic renal disease is admitted to the hospital for evaluation prior
to a surgical procedure. Which laboratory test indicates client's protein status for
the longest length of time? -✓✓Serum albumin
Rationale: Serum albumin has a long half-life.
• What client statement indicates to the nurse that the client requires assistance
with bathing? -✓✓"I don't understand why I'm so weak & tired."
• How should the nurse handle linens that are soiled with incontinent feces? -
✓✓Place the soiled linens in a pillow case & deposit them in the dirty linen
hamper
• When caring for an immobile client, what nursing diagnosis has the highest
priority? -✓✓Impaired gas exchange
• The nurse assesses an immobile, elderly male client & determines that his blood
pressure is 138/60, his temperature is 95.8F & his output is 100 mL of
concentrated urine during the last hour. He has wet sounding lungs & increased
respiratory secretions. Based on these assessment findings , what nursing action is
most important for the nurse to implement? -✓✓Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia
from occurring.
,• The home health nurse visits an elderly female client who had a brain attack 3
months ago & is now able to ambulate with the assistance of a quad cane. Which
assessment finding has the greatest implications for this client's care? -✓✓The
nurse notes there are numerous scatter rugs throughout the house
• The nurse removes the dressing on a client's heel that is cover a pressure sore 1"
in diameter & finds that there is straw-colored drainage seeping from the wound.
What description of this finding should the nurse include in the client's record? -
✓✓One-inch pressure sore draining serous fluid
• Medication is prescribed to be given QID. What schedule should the nurse use to
administer this Rx? -✓✓0800, 1200, 1600, 2000
• The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which
client is likely to tolerate a higher level of pain? -✓✓1 55y/o woman who has had
moderate low back pain for 3 months
Rationale: Experiences with the same type of pain that has successfully been
relieved makes it easier for the client to interpret the pain sensation and, as a result,
the client is better prepared to take steps to relieve the pain. All other clients are
having new experiences with pain.
• A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the
nurse, "Will it hurt to have my tonsils & adenoids taken out?" Which response is
best for the nurse to provide? -✓✓"It may hurt, but we'll give you medicine to help
you feel better."
• A low-sodium, low-protein diet is prescribed for a 45y/o client with renal
insufficiency & HTN, who gained 3lbs in the last month. The nurse determines that
, the client has been noncompliant with the diet, based on which report from the
24hr diet recall? -✓✓1. Snack of potato chips & diet soda
2. Lunch of tuna, carrots, fruit & coffee
3. Breakfast of eggs, bacon, toast & coffee
4. Bedtime snack of crackers & milk
• What intervention should the nurse include in the care plan for a client who is
being treated with an Unna's paste boot for leg ulcers due to chronic venous
insufficiency? -✓✓Check capillary refill of toes on lower extremity with Unna's
paste boot
Rationale: Boot becomes rigid after it dries, so it is important to check distally for
adequate circulation. No bandage should be put under it. Should be applied from
foot & wrapped towards knee. Acts as a sterile dressing & should not be removed
q8h. Weekly removal is reasonable.
• Male client with nursing diagnosis of "spiritual distress". What intervention is
best for the nurse to implement when caring for this client? -✓✓Use reflective
listening techniques when the client expresses spiritual doubts.
Rationale: Client should be consulted before involving chaplain.
• Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to
impending death." What intervention is best for the nurse to implement when
caring for this client? -✓✓Assist & support the client in establishing short-term
goals.