1. A client who has a diagnosis of complete placenta previa is admitted to
m m m m m m m m m m m m m
m the labor and delivery suite at 36 weeks gestation with contractions 5 min
m m m m m m m m m m m m
in frequency and 1 min in duration. Which of the following actions should
m m m m m m m m m m m m m
m the nurse take?
m m
A. Rupture the amniotic sac m m m
B. Medicate the client for pain m m m m
C. Prepare the client for a cesarean section
m m m m m m
D. Perform a vaginal exam m m m
…Ans>> Prepare the client for a Cesarean section
m m m m m m m
2. A nurse enters a client's room and finds the client lying on the floor in a
m m m m m m m m m m m m m m m
m puddle of water. Which of the following statements should the nurse document
m m m m m m m m m m m
1 m/ m71
, in an incident report?
m m m m
A. Client fell out of bed because an assistive personnel left the rails of the bed
m m m m m m m m m m m m m m
m down
B. Client's roommate thinks the client is confused and fell when getting out of
m m m m m m m m m m m m
m bed
C. Client appears to have slipped in water but reports no injuries
m m m m m m m m m m
D. Client found lying on the floor near the bedside table
m m m m m m m m m
…Ans>> Client found lying on the floor near the bedside table
mm m m m m m m m m m
3. A charge nurse on a pediatric unit is making assignments for a float
m m m m m m m m m m m m m
m nurse from the medical unit. Which of the following clients is appropriate
m m m m m m m m m m m
to assign to the float nurse?
m m m m m m
A. A 10-year-old client who has pneumonia and is receiving respiratory
m m m m m m m m m m
treatments
m
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
m m m m m m m m m m m m
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular
m m m m m m m m m m m m m
m septal defect tomorrowm m
D. A 14-year-old client who is scheduled for discharge today following
m m m m m m m m m m
placement of a Herrington rod
m m m m m
…Ans>> m A 10-year-old client who has pneumonia and is receiving respiratory
m m m m m m m m m m
m treatments
4. A nurse is preparing to administer vancomycin to a client who has an
m m m m m m m m m m m m m
2 m/ m71
,m infected wound. The nurse should plan to monitor for which of the
m m m m m m m m m m m
m following adverse reactions?
m m
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
…Ans>> Ototoxicity
mm
5. A nurse is assessing an infant who has water intoxication. Which of the
m m m m m m m m m m m m m
m following findings should the nurse expect?
m m m m m
A. Generalized edema m
3 m/ m71
, B. Elevated urine specific gravity m m m
C. Thready pulse m
D. Increased hematocrit m
…Ans>> Thready pulse mm m
6. A home health nurse is conducting an initial home visit for a client who
m m m m m m m m m m m m m m
m has terminal breast cancer. The client has two school-age children and a
m m m m m m m m m m m
m limited support system. Which of the following is the priority nursing
m m m m m m m m m m
m action?
A. Inform the client of available community resources
m m m m m m
B. Assist the client in finding child care options
m m m m m m m
C. Agree upon short-term goals for the client
m m m m m m
D. Ask the client about their understanding of the diagnosis
m m m m m m m m
…Ans>> Inform the client of available community resources
mm m m m m m m
7. A nurse in an emergency department is assessing a client who has a nasal
m m m m m m m m m m m m m m
m fracture. Which of the following findings should cause the nurse to suspect a
m m m m m m m m m m m m
m skull fracture? m
A. Clear fluid drainage from the nares
m m m m m
B. Report of pain around the eyes m m m m m
C. Dried blood in the mouth m m m m
D. Mandibular asymmetry m
4 m/ m71
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