After placing a 36-week-gesation newborn in an isolate and drying the infant with
several blankets, what should the nurse implement next?
Administer the vitamin K injection.
Remove the wet blankets and linens from the isolate.
Place erythromycin ophthalmic ointment in both eyes.
Open the door to assess the infant's vital signs.
A client in the third trimester of pregnancy complains of frequent nasal stiffness
and occasional nosebleeds. Her chest circumference has increased by 5 cm during
the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she
has an increased costal angle. Which intervention should the nurse implement?
Ask a nurse with more experience to validate the coastal angle finding
Ask the healthcare provider to evaluate the client’s respiratory status
Examine the client for sign of tissue anoxia, such as pallor
Record the respiratory findings in the clients record as normal
A terminally ill male hospice client who is at home is showing decreased awareness
of his surroundings. His appetite is poor and he often refuses oral intake of solids
and liquids. For the past several days he has been unable to get out of bed. Which
action should the hospice nurse implement?
Ask family to remain nearby, but in another room.
Encourage family to speak often with the client.
Teach family how to assist the client to a wheelchair.
Instruct family to offer client only soft, bland foods
A woman was admitted yesterday afternoon with severe abdominal pain. Her
pregnancy test and ultrasound were negative, so an exploratory laparotomy was
completed during the night. When coffee ground material is observed in the drainage
from the nasogastric tube (NGT), which Intervention should the nurse implement?
Verify correct placement of the nasogastric tube
Perform gastro cult test on the nasogastric drainage.
Listen for evidence of diminished bowel sounds.
, Irrigate the nasogastric tube with water until clear.
The nurse Is reviewing the laboratory values for a client with acute pancreatitis
who reports of the abdominal pain is not as severe as it was on admission. Which
laboratory test should the nurse review to evaluate the client's clinical recovery?
Lipase.
Creatinine.
Bilirubin.
Glucose
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 ml of dark red fluids has drained from the nasogastric tube
In the last hour. Which action should the nurse take first?
a. Determine the clients vital signs
b. Monitor urinary output hourly.
c. Notify the surgeon immediately.
d. Assess the client's level of pain.
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is
most important for the nurse to recommend to these clients?
a. Ensure supplemental oxygen and respiratory medications are available at all
times.
b. Use nasal or cough tissues followed by hand washing at all times.
c. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23)
vaccines.
d. Avoid large crowded areas during the colder months of the year
8. The mother of a one-month-old infant calls the clinic to report that the back
of her infant's head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and
active.
b. Turn the infant on the left side braced against the crib when sleeping.
c. Prop the infant in a sitting position with a cushion when not sleeping.
d. Place a small pillow under the infant's head while lying on the back.
, 9. A woman is brought to the labor and delivery unit after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which
action should the nurse perform first?
a. Inspect the perineum for lacerations.
b. Collect specimen for hemoglobin and hematocrit.
c. Massage the fundus and give an oxytocin agent
d. Place the infant to breast for bonding
10. A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider before administering the
prescribed dose?
a. Elevated white blood cell count.
b. Presence of gram positive bacteria in the sputum.
c. Decreased creatinine clearance
d. Elevated cholesterol and lipoproteins.
11. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating
Kussmaul breathing and has a severe headache along with nausea. Her
arterial blood gases (ABG) are: pH 7.50; PaCO, 30 mmH ; HCO, 24 mEq/L (24
mmol/L). Which assessment finding warrants Immediate intervention by the
nurse?
a. Muscle stiffness.
b. Abdominal pain.
c. Mental stupor.
d. Fruity breath.
12. When performing postural drainage on a client with Chronic Obstructive
Pulmonary Disease (COPD), which approach should the nurse use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast.
c. Obtain arterial blood gases (ABGs) prior to procedure.
d. Perform the drainage immediately after meals.
13. A young male client with testicular cancer has a living will that describes his
desire that no extraordinary measures be taken to save his life. The
healthcare provider knows the client has a good prognosis and refuses to
write a "do not resuscitate" (DR) prescription. Which action should the nurse
take?
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