A nurse is assessing an infant who has water intoxication. Which of the following
findings should the nurse expect? - ANS-bounding pulse
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed
nurse. Which of the following statements indicates the newly licensed nurse
understands the purpose of the technique - ANS-a. This technique decreases the risk of
subcutaneous infiltration
1. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan? - ANS-a. Monitor the client
for 1 hr after meals
A nurse notices smoke coming from a client's room and discovers a fire in the
wastebasket. After moving the client to safety, which of the followings is the priority
action? - ANS-a. Close the fire door on the unit
A nurse is assessing a client who has delirium due to a febrile illness. Which of the
following findings should the nurse expect? - ANS-a. Hallucinations
1. A nurse is caring for a client following an open colectomy. Which of the following
findings places the client at risk for delayed wound healing? - ANS-hyperemesis
1. A home health nurse is reviewing treatment goals with a client who has diabetes
mellitus. The nurse should evaluate which of the following laboratory tests to determine
effective long-term management of blood glucose levels? - ANS-A1C
1. A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client? - ANS-a. Use a dedicated
stethoscope
1. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the
following actions should the nurse take? - ANS-Tell the client to avoid drinking fluids 1 hr
before bedtime
1. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive
phototherapy. Which of the following interventions should the nurse include? - ANS-a.
,Place the newborn 45 cm from the light source
1. A nurse is planning care for a client who has schizophrenia and is having difficulty
expressing their feelings. Which of the following referrals should the nurse make? -
ANS-social worker
1. A nurse is caring for a client who has heart failure and has started taking a loop
diuretic. Which of the following findings indicates the client is experiencing an adverse
effect of the medication - ANS-decreased reflexes
1. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the
nurse a list of client reports. Which of the following client reports should the nurse
assess first? - ANS-indigestion
1. A nurse is caring for a client who has just returned to the unit following a
bronchoscopy. Which of the following actions by the assistive personnel requires the
nurse to intervene? - ANS-offer oral fluids to the client
1. A nurse on a medical unit has just received change-of-shift report. Which of the
following clients should the nurse assess first? - ANS-a. A 68 year old client who had a
myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10
1. A nurse is assessing a client prior to performing a blood draw. The nurse should
identify that an allergy to which of the following food can indicate that the client has an
allergy to latex? - ANS-avocados
1. A nurse is preparing to witness a client's signature on an informed consent for a
total knee arthroplasty. Which of the following client statements indicates the nurse
should contact the surgeon? - ANS-a. I am thankful there are no serious complications
from this type of surgery
1. A nurse is admitting a client who has antisocial personality disorder. Which of the
following client behaviors should the nurse identify as consistent with this disorder? -
ANS-a. Uses others for personal gain
1. A nurse is teaching the parent of a school-age child who has scabies about the
application of permethrin 5% cream. The nurse should include which of the following as
a potential adverse effect of the medication? - ANS-burning
1. A nurse is teaching a client who has a new prescription for digoxin. Which of the
, following statements should the nurse include in the teaching? - ANS-muscle weakness
1. A nurse is planning teaching for a client who is at 10 weeks of gestation and has a
history of urinary tract infections. Which of the following information should the nurse
plan to include in the teaching about UTI prevention? - ANS-a. Empty the bladder
before and after intercourse
1. A nurse is providing discharge teaching to a client who is postpartum and plans to
breastfeed. Which of the following should the nurse recommend the client increase in
their diet during lactation? - ANS-a. Calcium
1. A nurse is providing teaching about preventing mastitis to a client who is postpartum
and breastfeeding her newborn. Which of the following instructions should the nurse
include? - ANS-a. Try to have your baby empty your breasts with each feeding."
1. A nurse is caring for a client who reports chest pain. Which of the following findings
indicates myocardial damage? - ANS-a. Troponin I 1.8 ng/mL
1. A nurse is providing teaching about car seat safety to the parent of a term
newborn. Which of the following statements by the parent indicates an understanding
of the teaching? - ANS-a. "I should place my baby's car seat rear-facing until 6
months of age."
1. A nurse is performing high-frequency chest compressions using a mechanical
chest compression device for a child who has cystic fibrosis. Which of the following
findings indicates the treatment has been effective? - ANS-a. The child has increased
sputum production
1. A nurse is caring for a client following a possible exposure to anthrax. Which of the
following actions should the nurse take? - ANS-antitoxin
1. A nurse is caring for a client who has a newly implanted sealed internal radiation
device to treat cervical cancer. Which of the following is an appropriate action for the
nurse to take? - ANS-a. Keep a 3 foot distance from the radiation implant
A nurse is admitting a client to the medical-surgical unit. Which of the following actions
should the nurse take first? - ANS-a. Observe the client's level of mobility
1. A nurse at a public health clinic is caring for a group of clients. Which of the following
should the nurse identify as a reportable diagnosis to the CDC? - ANS-hep A
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