QUESTIONS 2026 COMPLETE REVIEW
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,The nurse is caring for 4 pediatric clients. After receiving 2. A 6-week-old infant admitted to the hospital for decreased level of
reports from the night shift, which child should the nurse consciousness; shaken baby syndrome is suspected
assess first?
The infant or child who is the most unstable should be assessed first. A 6-week-
1. A 6-year-old child being treated for bacterial meningitis old infant with an altered level of consciousness suspected to have resulted from
and on the tenth day of antibiotic treatment shaken baby syndrome is the most unstable client because the infant could be
2. A 6-week-old infant admitted to the hospital for developing increased intracranial pressure (ICP) and require interventions for the
decreased level of consciousness; shaken baby complications associated with increased ICP. The 6-year-old child on day 10 of
syndrome is suspected antibiotics for bacterial meningitis is a stable client. The 2-year-old child with
3. A 2-year-old child with cerebral palsy being admitted cerebral palsy being admitted for surgical placement of a gastrostomy tube will
to the hospital for surgical placement of a gastrostomy need an admission assessment, but this child is stable. The 16-year-old with a
feeding tube the next day possible shunt malfunction could become unstable, but because this child is older
4. A 16-year-old child with a ventriculoperitoneal shunt and ready for the CT scan, he or she is stable at this time.
that was placed at birth for hydrocephalus; possible
shunt malfunction is suspected, and the child is
scheduled and ready for a computed tomography (CT)
scan of the head
The nurse is assigned to care for 4 clients. Which client 4. A client who has a peripheral (index finger) oxygen saturation percentage of
should the nurse assess first? 85%
1. A client who has a tympanic temperature of 99.8º F An oxygen saturation percentage of 85% is abnormal. If this is an accurate
2. A client who has a regular radial pulse of 96 beats/min measurement, immediate intervention is needed to maintain the client's
3. A client who has a supine resting blood pressure of oxygenation status. A tympanic temperature of 99.8º F is mildly elevated and
148/90 mm Hg 4. A client who has a peripheral (index should be monitored, but it is a lower priority than respiratory status. A radial
finger) oxygen saturation percentage of 85% pulse of 96 beats/min is elevated as is the supine resting blood pressure of 148/90
mm Hg; both merit further assessment but are a lower priority than respiratory
status.
The nurse has received the client assignment for the day. 4. The client admitted with the medical diagnosis of neutropenia who is afebrile
Which client should the nurse care for first? and is complaining of pain with urination
1. The client receiving chemotherapy who is on day 3 of a The client admitted with neutropenia should be cared for first. The white blood
5-day regimen and has a question about nutrition cells serve as the primary defense against infections by destroying bacteria in the
2. The client receiving external radiation who has blood. The client is complaining of painful urination; therefore, the nurse should
complaints of dryness and itching skin at the treatment suspect urinary tract infection and act promptly to contact the primary health care
area provider because clients with neutropenia are more susceptible to bacterial
3. The client who had a radical mastectomy 36 hours ago infections. The client who is tolerating the chemotherapy regimen and has a
and is complaining of tightness and pulling at the incision question is not a priority. It is not urgent that the nurse see the client with dryness
site and itching from radiation first. This is an expected effect from radiation therapy.
4. The client admitted with the medical diagnosis of The client who has a mastectomy is expected to have sensations of tightness and
neutropenia who is afebrile and is complaining of pain pulling.
with urination
The nurse is the first responder at the scene of a train 3. A victim experiencing airway obstruction
accident. Which victim should the nurse attend to first?
Client needs related to maintaining a patent airway are always the priority.
1. A victim experiencing excruciating pain Therefore, the nurse would attend to the victim experiencing airway obstruction
2. A victim experiencing moderate anxiety first. Care to the other victims follows.
3. A victim experiencing airway obstruction
4. A victim experiencing altered level of consciousness
, A client with terminal cancer arrives in the emergency 2. Get directions about care from the client's sister
department unresponsive and in respiratory distress. The
client's sister is the legal medical power of attorney. Both A medial POA allows the client to designate a specific decision-making individual
the client's spouse and sister are present. Which action by who can advocate for the client as needed and can be flexible in changing
the nurse is appropriate at this time? circumstances. The client's sister is designated as her POA. Though spouses are
typically POA, option 1 is incorrect as he is not the designated POA. Option 3
1. Ask the spouse about the client's wishes would be appropriate only if there were no advance directives or family member
2. Get directions about care from the client's sister present. Option 4 delays treatment.
3. Prepare for emergency intubation
4. Request that the sister provide a living will
The nurse reads a journal article about a study using a 2. Do the characteristics of the sample population match those of the nurse's unit?
new pain management protocol for clients with terminal
cancer. What should the nurse first consider in When evaluating research for practice changes, the nurse must first determine if
determining whether the protocol is appropriate to there is reasonable similarity between the nurse's unit population and the study
implement on the unit? population to expect equivocal results.
1. Did the study have institutional review board approval?
2. Do the characteristics of the sample population match
those of the nurse's unit?
3. What are the credentials of the study's researcher?
4. What was the financial support provided for the study?
The charge nurse in the emergency department assigns a 2. 8 year old with a closed fracture of the clavicle following a fall who is talkative
client to a new nurse who has been off orientation for a and rates pain as a "2" on the 0-10 FACES pain scale
week. Which client assignment is most appropriate?
A fractured clavicle is not uncommon in children age <10 years and is usually
1. 3 year old with a temperature of 102.4 F (39.1 C) who treated conservatively. Additionally, the 8 year old has minimal pain and is
had a seizure at home 30 minutes ago and is very irritable therefore the most stable. The new nurse should be given the most stable patient.
2. 8 year old with a closed fracture of the clavicle
following a fall who is talkative and rates pain as a "2" on
the 0-10 FACES pain scale
3. 32 year old with asthma who has an upper respiratory
tract infection and a peak expiratory flow rate that is 45%
of personal best
4. 72 year old prescribe antibiotics 3 days ago to treat
acute sinusitis who reports shortness of breath and has a
rash
The nurse is caring for a hospitalized client with a 2. Assist the client to bathe and change the bed linens to maintain client comfort
diagnosis of thyrotoxicosis. Which of the following 3. Lower the room temperature and provide cool cloths on request
actions can be delegated to unlicensed assistive
personnel? Select all that apply. UAP are authorized to perform activities of daily living, hygiene, linen changes,
and positioning. Therefore, Option 2 and 3 are within a UAP's scope of practice.
1. Administer artificial tears if the client reports eye Option 1 involves medication administration, which is under the scope of a RN.
dryness Option 4 involves client teaching and also falls in the scope of practice of a RN.
2. Assist the client to bathe and change the bed linens to Although placing a phone call can be delegated, providing family with updates
maintain client comfort about the client's condition may require teaching and psychosocial support;
3. Lower the room temperature and provide cool cloths therefore, Option 5 is not an appropriate task for UAP.
on request
4. Reinforce to the client that fever is expected with
thyrotoxicosis
5. Return a call to the client's family telling them the
client's condition is unchanged