The nurse is has just admitted a client with severe depression. From which focus
should the nurse identify a priority nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety
The correct answer is D: Safety
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks
the nurse about how it is determined that a person has AIDS other than a positive HIV
test. The nurse responds
A) "The complaints of at least 3 common findings."
B) "The absence of any opportunistic infection."
C) "CD4 lymphocyte count is less than 200."
D) "Developmental delays in children."
The correct answer is C: "CD4 lymphocyte count is less than 200."
The nurse is caring for a child who has just returned from surgery following a
tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns
The correct answer is D: Observe swallowing patterns
A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the
nurse that she has everything ready for the baby and has made plans for the first weeks
together at home. Which normal emotional reaction does the nurse recognize?
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A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy
The correct answer is C: Anticipation of the birth
The nurse is planning care for a client with pneumococcal pneumonia. Which of the
following would be most effective in removing respiratory secretions?
A) Administration of cough suppressants
B) Increasing oral fluid intake to 3000 cc per day
C) Maintaining bed rest with bathroom privileges
D) Performing chest physiotherapy twice a day
The correct answer is B: Increasing oral fluid intake to 3000 cc per day
The nurse in a well-child clinic examines many children on a daily basis. Which of
the following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sip cup
The correct answer is D: A 30 month-old only drinking from a sip cup
Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration
The correct answer is D: Observe a return demonstration
A client has developed thrombophlebitis of the left leg. Which nursing intervention
should be given the highest priority?
A) Elevate leg on 2 pillows
B) Apply support stockings
C) Apply warm compresses
D) Maintain complete bed rest
The correct answer is A: Elevate leg on 2 pillows
A nurse from the surgical department is reassigned to the pediatric unit. The charge
nurse should recognize that the child at highest risk for cardiac arrest and is the least
likely to be assigned to
this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma
The correct answer is C: Prolonged hypoxemia
A home health nurse is at the home of a client with diabetes and arthritis. The client
has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the
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