CORRECT DETAILED ANSWERS WITH RATIONALES
ALREADY GRADED A+NEWEST AND LATEST VERSION
A nurse in an emergency department completes an assessment on an adolescent client that has
conduct disorder. The client threatened suicide to a 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?
CORRECT ANS: Tell me how often do you drink alcohol
A nurse is observing bonding to the client her newborn. Which of the following actions by the
client requires the nurse to intervene?
A- Holding the new born in an end face position
b- asking the father to change the newborns diaper
c- requesting the nurse to take the newborn nursery so she can rest
d- Viewing the newborns actions to be uncooperative
CORRECT ANS: Viewing the newborns actions to be uncooperative
A nurse is caring for a client who is taking levothyroxine. Which of the following findings should
indicate that the medication is effective?
A- Weight loss
,b- Asking the father to change the newborns diaper
c- absence of seizures
d- Decrease inflammation
CORRECT ANS: Weightloss this drug acts as T4 and will normalize the effects of hypothyroidism
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 the provider if the cord still turns black
b- clean the base of the cord with hydrogen peroxide daily
c- Keep the cord dry unitl it falls off
d- The cord stump will fall off in five days
CORRECT ANS: Keep the cord dry until it falls off (cord should be kept clean and dry to prevent
infection, it will turn black, clean with neutral ph cleanser, cord falls off in 10-14 days)
A nurse is assessing a client in PACU. Which of the following findings indicates decreased cardiac
output?
A- Shivering
b- oliguria
c- Bradypnea
d- Constricted pupils
CORRECT ANS: Oliguria
A nurse is assisting with mass casualty triage, explosion at a local factory. Which of the following
client should the nurse identify as the priority?
,A- A client that has massive head trauma
B- A client has full thickness burns to face and trunk
C- A client with indications of hypovolemic shock
D- A client with open fracture of the lower extremity
CORRECT ANS: A client with indications of hypovolemic shock
A nurse is receiving report on four clients. Which of the following clients should the nurse asses
first?
A- a client who has illegal conduit and mucus in the pouch
b- Client pleasant arteriovenous additional vibration palpated
c- Client whose chronic kidney disease with cloudy diasylate outflow
D- A client was transurethral resection of the prostate with red tinged urine in the bag
CORRECT ANS: 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
CORRECT ANS: Provide standby assist with the client from bed
, A nurse is caring for a client who is in labor and his seat is recieving electronic fetal monitoring.
The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following
should the nurse expect?
a-Feta hypoxia
b- abrupto placentae
c- post maturity
d- head compressions
CORRECT ANS: head compressions
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of
the following laboratory values as an indication for hemodialysis?
a- Glomerular filtration rate of 14 ml/minute
b- BUN 16 ml/dl
c- serum magnesium 1.8 mg mg/dl
d- serum phosphorus 4.0 m mg/dl
CORRECT ANS: glomerular filtraion 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 hrs
c- heat the skin one minute prior to placing the program