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Exam A, 2020 exit v 2 latest 2025/
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The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees -correct answerB Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D). When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L -correct answerB Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D). Which vaccination should the nurse administer to a newborn? A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine -correct answerA Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D). The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.Assess the need to change a central line dressing. B.Obtain a fingerstick blood glucose level. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen. - correct answerB Rationale:
Exam A, 2020 exit v 2 latest 2025/
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Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.) A.Administer aspirin with tissue plasminogen activator (t-PA). B.Complete the National Institute of Health Stroke Scale (NIHSS). C.Assess the client for signs of bleeding during and after the infusion. D.Start t-PA within 6 hours after the onset of stroke symptoms. E.Initiate multidisciplinary consult for potential rehabilitation. -correct answerB,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D). When caring for a client in labor, which finding is most important to report to the primary health care provider? A.Maternal heart rate, 90 beats/min. B.Fetal heart rate, 100 beats/min C.Maternal blood pressure, 140/86 mm Hg D.Maternal temperature, 100.0° F -correct answerB Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal findings for a woman in labor. The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A.Draw arterial blood gases. B.Notify the primary health care provider. C.Position in a high Fowler's position with the legs down. D.Obtain a chest X-ray. -correct answerC Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).
Exam A, 2020 exit v 2 latest 2025/
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Rationale: An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for hemorrhage (C). While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? A.Transfer the call into the room of the client. B.Instruct the secretary to explain reason for the call. C.Ask another nurse to take the phone call. D.Ask the health care provider to see the client on the unit. -correct answerC Rationale: Another nurse should be asked to take the phone call (C), which allows the nurse to stay at the bedside to complete the assessment of the client's chest pain. (A and B) should not be done during an acute change in the client's condition. Requesting the health care provider (D) to come to the unit is premature until the nurse completes assessment of the client's status. Which instruction(s) should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A.Keep the medication in your pocket so that it can be accessed quickly. B.Call 911 if chest pain is not relieved after one nitroglycerin. C.Store the medication in its original container and protect it from light. D.Activate the emergency medical system after three doses of medication. E.Do not use within 1 hour of taking sildenafil citrate (Viagra). -correct answerB,C Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E). The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial.
Exam A, 2020 exit v 2 latest 2025/
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B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C.Avoid combining the two insulins because incompatibility could cause an adverse reaction. D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick. -correct answerB Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D). An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.Notify the health care provider that the child's pulse rate is below normal for her age group. -correct answerA Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D). The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 pounds. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 ml. Which is the correct dosage indicated on the image? A.30ml B.15ml C.10ml D.5ml -correct answerB Rationale:
Exam A, 2020 exit v 2 latest 2025/
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Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C). The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.) A.Dark red vaginal bleeding B.Rigid boardlike abdomen C.Soft abdomen on palpation D.Complaints of severe abdominal pain E.Painless bright red vaginal bleeding -correct answerA,B,D Rationale: These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E). Which vital sign in a pediatric client is most important to report to the primary health care provider? A.Newborn with a heart rate of 140 beats/min B.Three-year-old with a respiratory rate of 28 breaths/min C.Six-year-old with a heart rate of 130 beats/min D.Twelve-year-old with a respiratory rate of 16 breaths/min -correct answerC Rationale: The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min (C). The others are all within normal range for those ages (A, B, and D). Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? A.The client reports a continuous feeling of needing to void. B.Urinary drainage is pink 24 hours after surgery. C.The hemoglobin level is 8.4 g/dL 3 days postoperatively. D.Sterile saline is being used for bladder irrigation. -correct answerC Rationale: A hemoglobin level of 8.4 g/dL is abnormally low and may indicate hemorrhage (C). The others are all expected findings after a TURP (A, B, and D). Which of the following cardiac rhythms is represented in the image? A.Normal sinus rhythm B.Sinus tachycardia C.Ventricular fibrillation D.Atrial fibrillation -correct answerC Rationale:
Exam A, 2020 exit v 2 latest 2025/
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Ventricular fibrillation (C) is a life-threatening arrhythmia characterized by irregular undulations of varying amplitudes. (A, B, and D) are not represented in the image. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? A.Long-acting medication is more effective than daily medication. B.A client with substance abuse must not take any oral medications. C.There will continue to be a risk of alcohol and drug interaction. D.Support groups are only helpful for substance abuse treatment. -correct answerC Rationale: Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect information. A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make? A."It's normal to feel ambivalent about a pregnancy when you are not feeling well." B."I think you should discuss these feelings with your health care provider." C."How does the father of your child feel about your having this baby?" D."Tell me about these second thoughts you are having about this pregnancy." -correct answerD Rationale: Although ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It is reflective and keeps the lines of communication open. (A) is not the best response because it offers false reassurance. (B) dismisses the client's feelings. The nurse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be discussed, but it is not the most important information to obtain at this time. A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) A.Abdominal obesity B.Sedentary lifestyle C.History of hypoglycemia D.Hispanic or Asian ethnicity E.Increased triglycerides -correct answerA,B,D,E Rationale:
Exam A, 2020 exit v 2 latest 2025/
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Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (B). Placing the dominant hand on the client's forehead (C) stabilizes the hand so the nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (A); asking the client to close the eye gently helps distribute the medication (D). A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone (Risperdal). The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to obtain? A.Compliance with medication regimen B.Current thyroid-stimulating hormone (TSH) level C.Occurrence of mania or depression D.A 24-hour diet and exercise recall -correct answerA Rationale: Medication compliance (A) is most important for the treatment of psychotic disorders and, because Risperdal is associated with weight gain, it is probable that the client is complying with the treatment plan. The TSH level (B) indicates thyroid function, which regulates basal metabolic rate and influences weight. It is important to obtain information about occurrences of mania and depression (C) since the last visit, but if the client is compliant with the medication regimen, these symptoms are likely to have been controlled. Diet and exercise (D) should also be assessed, but weight gain is a likely indicator of medication compliance. The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client's care? A.Palpate for pitting edema. B.Provide meticulous skin care. C.Administer phosphate binders. D.Monitor serum potassium levels. -correct answerD Rationale: Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be life threatening (D). One sign of fluid retention is pitting edema (A), but it is an expected symptom of renal failure and is not as high a priority as (D). (B and C) are common nursing interventions for CRF but not as high a priority as (D). A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? A.Fever, elevated white blood count, elevated platelets B.Fatigue, weight loss and anorexia, elevated red blood cells C.Hyperplasia of the gums, elevated white blood count, weakness
Exam A, 2020 exit v 2 latest 2025/
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D.Hypocellular bone marrow aspirate, fever, decreased hemoglobin level -correct answerC Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia (C). (A, B, and D) state incorrect information for symptoms of leukemia. Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? A.Accelerations in response to fetal movement B.Early decelerations in the second stage of labor C.Fetal heart rate of 130 beats/min between contractions D.Late decelerations with absent variability and tachycardia -correct answerD Rationale: Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous (D). 130 beats/min is an expected heart rate (C). The others are not as critical (A and B). Which disaster management intervention by the nurse is an example of primary prevention? A.Emergency department triage B.Follow-up care for psychological problems C.Education of rescue workers in first aid D.Treatment of clients who are injured -correct answerC Rationale: Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury (C). (A) is an example of secondary prevention. (B) is an example of tertiary prevention. (D) is an example of secondary prevention. The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is less than 2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process? A.Assessment B.Planning C.Implementation D.Evaluation -correct answerB Rationale: Planning (B) allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. Assessment, implementation, and evaluation are
Exam A, 2020 exit v 2 latest 2025/
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appropriate respiratory equipment for airborne precautions. A surgical mask is used for preventing transmission of droplet precautions. The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? A.Ammonia odor is noted when the catheter is emptied. B.240 mL of urinary output is produced in 12 hours. C.A 16-French catheter was used for an adult female. D.Drainage system is hanging below the level of the bladder. -correct answerB Rationale: An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14- to 18-French catheters are common sizes used in the adult female (C). Below the level of the bladder is the correct position for the drainage bag (D). An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A.Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B.Explain that treatment is based on information obtained in the assessment. C.Encourage the client to relax so that she can provide the information requested. D.Empower the client to share her story of why she is here at the mental health clinic. - correct answerD Rationale: The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. (D) is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax (C) is likely to increase her anxiety. Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A.States having difficulty with color perception B.Presents with opacity of the lens upon assessment C.Complains of seeing a cobweb-type structure in the visual field D.Reports the need to use a magnifying glass to see small print -correct answerC Rationale:
Exam A, 2020 exit v 2 latest 2025/
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Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss (D) are expected signs and symptom of cataracts, but do not need immediate attention. Which intervention(s) should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) A.Maintain bed rest for the first 6 hours after delivery. B.Palpate and massage the fundus to maintain firmness. C.Have client empty bladder if fundus is above umbilicus. D.Check perineal pad for color and consistency of lochia. E.Apply ice pack or witch hazel compresses to the perineum. -correct answerB,D,E Rationale: The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C). The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? A.0. B.1. C. D.9 -correct answerD Rationale:15 mg/kg × 15 kg = 225 mg to be administered Supply = 125 mg/5 mL (5 mL/125 mg) × 225 mg = 9 mL or (225 mg/125 mg) × 5 ml = 9 mL Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? A.Auscultation of vesicular breath sounds B.Pulse oximetry reading of 89% C.Arterial Pao2 of 86% D.Resonance on percussion of the lungs -correct answerB Rationale: An oxygen saturation lower than 90% indicates hypoxia (B). (A, C, and D) are all normal findings.
Exam A, 2020 exit v 2 latest 2025/
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C.Use a tongue blade to open the airway. D.Turn client on the side to aid ventilation. -correct answerD Rationale: Maintaining airway during a seizure is priority for safety (D). (A, B, and C) are contraindicated during a seizure and may cause further injury to the client. When assessing safety for the older adult, which of the following is of highest priority to the nurse? A.The client has a cataract in the right eye. B.The client is not married and lives alone. C.The client lives in a two-story building. D.The client reports a history of repeated falls. -correct answerD Rationale: Risk assessment for falls is a critical element in caring for the older adult. (A, B, and C) are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again (D). The nurse expects a clinical finding of cyanosis in an infant with which condition(s)? (Select all that apply.) A.Ventricular septal defect (VSD) B.Patent ductus arteriosis (PDA) C.Coarctation of the aorta D.Tetralogy of Fallot E.Transposition of the great vessels -correct answerD,E Rationale: Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). The others are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects. (A, B, and C). A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? A."I will not take my digoxin if my heart rate is higher than 100 beats/min." B."I should weigh myself once a week and report any increases." C."It is important to increase my fluid intake whenever possible." D."I should report an increase of swelling in my feet or ankles." -correct answerD Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider (D). Digitalis should be held when the heart rate is lower than 60 beats/min (A). The client with heart failure should weigh himself or
Exam A, 2020 exit v 2 latest 2025/
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herself daily and report a gain of 2 to 3 lb (B). An increase in fluid can worsen heart failure (C). Which action by the nurse is consistent with culturally competent care? A.Treating each client the same regardless of race or religion B.Ensuring that all Native American clients have access to a shaman C.Understanding one's own world view in addition to the client's D.Including the family in the plan of care for older clients -correct answerC The nurse should understand his or her own values and views to prevent those values from being imparted to others, in addition to understanding the client's cultural views (C). Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity (A, B, and D). The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A."I know many women who have survived ovarian cancer." B."Let's talk about the treatments of ovarian cancer." C."In my opinion I would suggest getting a second opinion." D."Tell me about what you are feeling right now." -correct answerD Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings (D). Giving false reassurance or personal suggestions are not therapeutic communication for the client (A, B, and C). A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? A."The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what you say." B."You can be assured that I will keep all of our conversations confidential because it is important that you can trust me." C."For your safety and well-being, it may be necessary to share some of our conversations with the health care team." D."I am legally required to document all of our conversations in the electronic medical record." -correct answerC Rationale: Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy (C). HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue (A). Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue (B). Although pertinent information should be
Exam A, 2020 exit v 2 latest 2025/
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Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? A.Limit fluids to prevent infection to the surgical site. B.Place the infant in the prone position. C.Provide a low-residue diet to limit bowel movements. D.Cover sac with a moist sterile dressing. -correct answerB Rationale: The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum (B). Fluids should be increased postoperatively to prevent dehydration (A). A high-fiber diet should be implemented to prevent constipation (C). After the repair, the sac is no longer exposed, so (D) does not apply. Which intervention(s) should the nurse implement when administering a new prescription of amitriptyline HCl (Elavil) to a client with a depressive disorder? (Select all that apply.) A.Explain that therapeutic effects should be achieved within 1 to 3 days. B.Administer at bedtime to minimize sedative effects. C.Give 1 hour after the administration of isocarboxazid (Marplan). D.Take blood pressure prior to and after administration. E.Assess for adverse reactions such as dry mouth and blurred vision. -correct answerB,D,E Rationale: The drug causes sedation, so it should be given at bedtime (B). Cardiovascular adverse reactions include orthostatic hypotension; therefore, the blood pressure should be assessed (D). This drug can cause anticholinergic effects such as dry mouth, blurred vision, constipation, and urinary retention (E). The drug takes 2 to 6 weeks to achieve therapeutic effects (A). All monoamine oxidase (MAO) inhibitors such as isocarboxazid should be discontinued 1 to 3 weeks prior to the administration of Elavil (C). When administering an intramuscular injection, which factor is most important to ensure the best medication absorption? A.Compress the syringe plunger quickly. B.Select a small-gauge needle. C.Inject the needle at a 90-degree angle. D.Select a small-diameter syringe. -correct answerC Rationale: Injecting the needle at a 90-degree angle allows the medication to be injected into the muscle so that appropriate absorption can occur (C). Too rapid injection of the medication (A) may be painful and may cause medication leakage and reduced absorption. (B) will reduce injection discomfort but will not affect absorption. A syringe barrel that is too small (D) increases the pressure during the injection and may traumatize tissue without improving medication absorption.
Exam A, 2020 exit v 2 latest 2025/
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When assessing a normal newborn, which finding(s) should the nurse expect? (Select all that apply.) A.Umbilical cord contains one vein and two arteries B.Slightly edematous labia in the female newborn C.Absence of Babinski reflex D.Presence of white plaques on the cheeks and tongue E.Nasal flaring noted with respirations -correct answerA,B Rationale: These are normal findings (A and B). The others indicate abnormalities or complications and should be reported to the primary health care provider (C, D, and E). The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A.An 18-year-old woman who had a positive pregnancy test and wants advice on how to tell her parents B.A woman with type 1 diabetes who has just discovered she is pregnant and is worried about her fingerstick glucose C.A women at 24 weeks of gestation crying about painful genital lesions on the vulva and urinary frequency D.A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn -correct answerD Rationale: The women with epigastric pain should be called first (D). One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. (A, B, and C) are less serious and should be called after (D). The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the licensed practical nurse (LPN)? A.A client with nausea who needs a nasogastric tube inserted B.A client in hypertensive crisis who needs titration of IV nitroglycerin C. A newly admitted client who needs to have a plan of care established D.A client who is ready for discharge who needs discharge teaching -correct answerA Rationale: This client has a need for a skill that is within the scope of practice for the LPN (A). Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated (B, C, and D). A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? A.A 17-year-old who is sexually active with numerous partners
