The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary r...
The nurse is completing the admission assessment of a 3-year old who is h
admitted meningitis
bacterial wit and hydrocephalus. Which assessment finding is
evidence
child that the
is experiencing increased intracranial pressure
(ICP)?
A. Tachycardia and
tachypnea
B. Sluggish and unequal pupillary
responses
C. Increased head circumference and bulging
fontanels
D. Blood pressure fluctuations and syncope correct answers B. Sluggish and
unequal
pupillary
responses
A client with acute pancreatitis is admitted with severe, piercing abdominal
pain and an
elevated serum amylase. Which additional information is the client most
likely
to theto report
nurse?
A. Abdominal pain decreases when lying
supine
B. Pain lasts an hour and leaves the abdomen
tender
C. Right upper quadrant pain refers to right
scapula
D. Drinks alcohol until intoxicated at least twice weekly. correct answers A.
Abdominal
pain decreases when lying
supine
A child newly diagnosed with sickle cell anemia (SCA) is being
discharged
hospital. frominformation
Which the is most important for the nurse to provide the
to
parents prior
discharge?
A. Instructions about how much fluid the child should
drink
B. daily.
Signs of addiction to opioid pain
medications
C. Information about non-pharmaceutical pain relief
D. Referral for social services for the child and family correct answers A.
measures
Instructions
about how much fluid the child should
drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at
what location.
(Select the location on the image with a red dot). correct answers I placed
thethe
on redbase
dot of the neck on the
right side
After receiving report on an inpatient acute care unit, which client
should the nurse
assess
first?
A. The client with an obstruction of the large intestine who is experiencing
abdominal
distentio
n
B. The client who had surgery yesterday and is experiencing a paralytic
ileus with
absent bowel
sounds
C. The client with a small bowel obstruction who has a nasogastric tube that
is draining
greenish
fluid
,D. The client with a bowel obstruction due to a volvulus who is experiencing
abdominal
rigidity correct answers D. The client with a bowel obstruction due to a
volvulus who abdominal
experiencing is
rigidity
A teenager presents to the emergency department with palpitations after
vapingThe
party. at aclient is anxious, fearful, and hyperventilating. The nurse
anticipates
client the which acid base
developing
imbalance?
A. Respiratory
acidosis
B. Metabolic
alkalosis
C. Metabolic
acidosis
D. Respiratory alkalosis correct answers D. Respiratory
alkalosis
A client with dyspnea is being admitted to the medical unit. To best
preparearrival,
client's for the the nurse should ensure that the client's bed is in
which position?
A.
Supine
B. supine; feet elevated higher than
head
C. supine; head elevated higher
than
D. feet correct answers
Fowlers
Fowlers
The nurse is taking the blood pressure measurement of a client with
Parkinson's
disease. Which information in the client's admission assessment is
relevantplan
nurse's to the
for taking the blood pressure reading? (Select all
theFrequent
A. apply)
syncope
B. Occasional
nocturia
C. Flat
affect
D. Blurred
vision
E. Frequent drooling correct answers A. Frequent
syncope
C. Flat
affect
D. Blurred
vision
While caring for a client's postoperative dressing, the nurse observes
purulent
at drainage
the wound. Before reporting this finding to the healthcare provider, the
nurse should
review which of the client's laboratory
values?
A. Serum
albumin
B. Culture for sensitive
organisms
C. Serum blood glucose
D. Creatinine level correct answers B. Culture for sensitive
level
organisms
A preschool-aged boy is admitted to the pediatric unit following successful
resuscitation
from a near-drowning incident. While providing care to the child, the
nurse begins
talking with his preadolescent brother who rescued the child from the
swimming
and pool
initiated resuscitation. The nurse notices the older boy becomes
withdrawn
asked aboutwhen
what happened. Which action should the
nurse
A. take?a water safety teaching plan for the
Develop
family
B. Ask the older brother how he felt during the
incident
C. Tell the older brother that he seems
depressed
,D. Commend the older brother for his heroic actions correct answers B.
Ask the how
brother olderhe felt during the
incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse
that he
been has in hot baths at night with no relief of his discomfort. Which
soaking
action
the should
nurse
take?
A. Encourage the client to use cooler water and apply calamine lotion
after
B. soaking
Obtain a PRN prescription for an analgesic that the client can use for f
symptom
C. Suggestrelie
that the client take brief showers and apply oil-based lotion after
showering
D. Explain that the symptoms are caused by liver damage and cannot
be relieved
correct answers A. Encourage the client to use cooler water and apply
calamine lotion
after
soaking
An older client with a long history of coronary artery disease (CAD),
hypertension
(HTN), and heart failure (HF) arrives in the Emergency Department (ED) in
respiratory
distress. The healthcare provider prescribes furosemide IV. Which therapeutic
response
to furosemide should the nurse expected in the client with
acute
A. HF?
Increased cardiac
contractility
B. Reduced
preload
C. Relaxed vascular
tone
D. Decreased afterload correct answers B. Reduced
preload
Which intervention should the nurse include in the plan of care for a child
with
A. tetanus? coughing and deep
Encourage
breathing
B. Minimize the amount of stimuli in the
room
C. Reposition from side to side every
hour
D. Open window shades to provide natural light correct answers B.
Minimize
amount ofthe stimuli in the
room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the
age of 9, is
admitted to the hospital in diabetic ketoacidosis. Which occurrence is the
most likely
cause of the
ketoacidosis?
A. Ate an extra peanut butter sandwich before
gym
B. class
incorrectly administered too much
insulin
C. Had a cold and ear infection for the past
twoSkipped
D. days eating lunch correct answers C. Had a cold and ear infection
for the past
two
days
A client with a prescription for "do not resuscitate" (DNR) begins to
manifest signs
impending of After notifying the family of the client's status, what
death.
prioritythe
should action
nurse
implement?
A. The impending signs of death should be
documented
B. The client's status should be conveyed to the
chaplain
C. The client's need for pain medication should be
determined
D. The nurse manager should be updated on the client's status correct
answersneed
client's C. The
for pain medication should be
determined
, Which self care measure is most important for the nurse to include in the
plan
a of care
client of diagnosed with type 2 diabetes
recently
mellitus?
A. Self-injection
techniques
B. Blood glucose
monitoring
C. Diabetic diet meal
planning
D. A realistic exercise plan correct answers B. Blood glucose
monitoring
A client who gave birth 48 hours ago has decided to bottle feed the infant.
During the the nurse observes that both breasts are swollen, warm, and
assessment,
tender on Which instruction should the nurse
palpation.
provide?
A. Apply ice to the breasts for
comfort
B. Wear a loose-fitting bra during the day to prevent nipple
irritation
C. Run warm water over
breasts
D. Express small amounts of milk from the breasts to relieve pressure
correct
A. Applyanswers
ice to the breasts for
comfort
The nurse is preparing a client who had a below-the-knee (BKA)
amputation
discharge tofor
home. Which recommendations should the nurse provide
this client?
(Select all that
apply)
A. Avoid range of motion
exercises
B. Use a residual limb
shrinker
C. Apply alcohol to the stump after
bathing
D. Inspect skin for
redness
E. Wash the stump with soap and water correct answers B. Use a
residual limb
shrinke
rD. Inspect skin for
redness
E. Wash the stump with soap and
water
A toddler presenting with a history of intermittent skin rashes, hives,
abdominal
and vomiting pain,
that occurs after ingesting of milk products arrives
to the clinic by the parents. Which type of testing should the nurse provide
accompanied
education
to the toddler's family
about?
A. Serum immunoglobulin E
(IgE)
B. Intradermal
test
C. Atopy patch
D. Placebo-controlled food challenge correct answers A. Serum
test
immunoglobulin E
(IgE
)
A client who is scheduled for a bronchoscopy in the morning is anxious and
askingnumerous
nurse the questions about the procedure. In preparing the
client for the
procedure, which intervention has the highest
priority?
A. Allow client to gargle with warm saltr
wate
B. Administer a sedative to alleviate
anxiety
C. Instruct client to write down the
questions
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