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A nurse is observing bonding to the client her newborn. Which of following actions by the client requires
the nurse to intervene?
a) Holding the newborn in face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
d) Viewing the newborn's actions to be uncooperative - ANSWER d) Viewing the newborn's actions to be
uncooperative
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions
would you include in the teaching?
a) Contact provider if the cord still turns black
b) Clean the base of the cord with hydrogen peroxide daily
c) Keep the cord dry until it falls off
d) The cord stump will fall off in five days - ANSWER c) Keep the cord dry until it falls off
A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac
output?
a) Shivering
b) Oliguria
c) Bradypnea
d) Constricted pupils - ANSWER b) Oliguria
A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first?
,a) A client who has illeal conduit and mucus in the pouch
b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged urine in the bag - ANSWER c) A
client whose chronic kidney disease with cloudy diasylate outflow
A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate
nursing intervention?
a) Place's cardiac monitoring
b) Monitor the clients oxygen saturation level
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium - ANSWER c) Provide standby assist with the client from bed
A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The
nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the
nurse expect?
a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
d) Head Compression - ANSWER d) Head Compression
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the
following laboratory values as in an indication for hemodialysis?
a) glomerular filtration rate of 14 mL/ minute
b) BUN 16 mg/DL
c) serum magnesium 1.8 mg mg/dl
d) Serum phosphorus 4.0 mg/dL - ANSWER a) glomerular filtration rate of 14 mL/ minute
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an
appropriate action for the nurse to take?
a) Placed infant under radiant warmer
,b) Move the probe site every 3 hours
c) Heat the skin one minute prior to placing the program
d) Placed a sensor on the index finger - ANSWER c) Heat the skin one minute prior to placing the
program
A nurse in a mental health facility receives a change of shift report on for clients. Which of the following
clients should the nurse plan to assess first?
a) Client placed in restraints to the aggressive behavior
b) A new limited client pleasures history of 4.5 kg weight loss in the past two months
c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
d) Applied he'll be receiving his first ECT treatment today - ANSWER a) Client placed in restraints to the
aggressive behavior
A nurse in an emergency department completes an assessment on an adolescent client that has conduct
disorder. The client threatened suicide to teacher at school. Which of the following statements should
the
nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
c) Tell me how often do you drink alcohol
d) Tell me about your school schedule - ANSWER c) Tell me how often do you drink alcohol
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of non-
pharmacological pain management. Which of the following statements by the nurse is an appropriate
description of the use of hypnosis during labor?
a) Hypnosis focuses on the biofeedback as a relaxation technique
b) Hypnosis promotes increased control of her pain perception during contractions
c) Hypnosis uses therapeutic touch to reduce anxiety during labor
d) Hypnosis provides instruction to minimize pain - ANSWER b) Hypnosis promotes increased control of
her pain perception during contractions
, A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for
theft is addressing the group. Which of the following is an example of reaction formation?
a) I steal things because it's the only way I can keep my mind off my bad marriage
b) I can't believe I was accused of something I didn't do
c) I don't want talk about my feelings right now. We will talk more next time
d) I think that people just you're just lazy and should earn money honestly - ANSWER d) I think that
people just you're just lazy and should earn money honestly
A nurse is obtaining the medical history of a client who has a new prescription for isosorbide
monotitrate. Which of the following should the nurse identify as a contraindication to medication?
a) Glaucoma
b) Hypertension
c) Polycythemia
d) Migraine headaches - ANSWER a) Glaucoma
The nurses is caring for a client recovering from an acute myocardial infarction. Which following
intervention should the nurse include in the point of care?
a) Draw a troponin level every four hours
b) Performance EKG every 12 hours
c) Plant oxygen tent fell over minutes via rebreather mask
d) Obtain a cardiac rehabilitation consult - ANSWER d) Obtain a cardiac rehabilitation consult
A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which
of
the following laboratory values should nurse report to provider?
a) WBC 3,000/mm3
b) Hemoglobin 14 g/dl
c) Platelet 250,000/mm3
d) aPTT 30 seconds - ANSWER a) WBC 3,000/mm3
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