1. A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings
should indicate to the nurse that the therapy has been effective?: hemoglobin 14.9 g/dL
2. a nurse working in an emergency department is triaging four clients. which of the following clients should the
nurse recommend for treatment first?: a middle adult client who has unstable vital signs
3. a nurse is caring for a client who has fluid volume overload. which of the following tasks should the nurse
delegate to an assistive personnel?: mea- sure the client's daily weight
4. a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has
severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer?: 18 g
5. a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs,
which of the following images indicates the adolescent is abducting the hip joint?: Moving the leg away from the
midline of the body (off to the side, not to the front)
6. a nurse is caring for a client who has hyperthyroidism. which of the following findings should the
nurse expect?: tremors
tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair,
bradycardia, and periorbital edema
7. a nurse is assessing a school age child who has bacterial meningitis. which of the following findings
should the nurse expect?: nuchal rigidity also weight loss
8. a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take?: auscultate the
apical pulse at least 1 min
9. a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to perform
which of the following actions?: - instruct the client to avoid coughing during the procedure
10. a nurse is the emergency department is assessing a preschooler who has a facial laceration. the nurse should
identify which of the following findings as a potential indication of child sexual abuse?: the child exhibits
discomfort while walking
,11. a nurse is preparing to teach about dietary management to a client who has crohn's disease and an
enteroenteric fistula. which of the following nutrients should the nurse instruct the client to decrease in their
diet?: fiber
- reduce diarrhea and inflammation
12. a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine following
a total knee arthroplasty. which of the following actions should the nurse take?: Turn off the CPM machine during
mealtime
promote client comfort and dietary intake
13. a nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse
select when initiating the IV for this client?: radial vein of the inner arm
14. a nurse is developing a client education program about osteoporosis for older adult clients. the nurse should
include which of the following variables as a risk factor for osteoporosis?: sedentary lifestyle
also, small framed body with a thin build, estrogen deficiency
15. a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the trunk
and extremities. which of the following interventions should the nurse identify as the priority?: initiate
transmission based precautions
16. a nurse is caring for a client who has a clogged percutaneous gastros- tomy feeding tube. which of the
following actions should the nurse take first?: change the position of the client
17. a home health care nurse is developing a teaching plan for a client who has a new ileostomy. which of the
following instructions should the nurse include?: empty the appliance when it is one third to one half full
18. a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received
hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?: sodium
148 mEq/L
19. a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive
personnel?: Arrange the lunch tray for a client who has a hip fracture
20. a nurse is preparing a client for a paracentesis. which of the following actions should the nurse take?:
instruct the client to void
, 21. a nurse has received change of shift report on four assigned clients. for which of the following clients should
the nurse intervene to prevent a potential food and medication interaction?: a client who is receiving an MAOI
and is requesting a cheeseburger for dinner
22. a nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple
joints. which of the following actions should the nurse plan to take?: allow for frequent rest periods throughout the
day
23. a nurse is caring for a client who is receiving continuous bladder irri- gation following a transurethral
resection of the prostate. the client reports bladder spasms, and the nurse observes a decreased urinary output.
which of the following actions should the nurse take?: irrigate the catheter with 0.9% sodium chloride irrigation
24. a nurse is assessing a client who has COPD. which of the following findings should the nurse expect?:
pH 7.31
25. a nurse in a community center is providing an educational session to a group of client about ovarian cancer.
which of the following manifestations of ovarian cancer should the nurse include in the teaching?: abdominal
bloating
increase in abdominal girth, pelvic or abdominal pain, early satiety, urinary fre- quency of urgency
26. a nurse is caring for a client who has active tuberculosis TB. which of the following actions should the nurse
plan to take to prevent the transmission of the disease?: Have the client wear a surgical mask while being
transported outside the room
27. a nurse is caring for a group of clients. which of the following clients should the nurse attend to first?: an
older adult client who is anxious and attempting to pull out an IV line
28. an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed.
for which of the following situations should the nurse intervene?: The LPN and the AP grasp the client under his
arms to lift him up in bed
29. a nurse is preparing to administer insulin to a client via a pen device. which of the following actions should
the nurse take?: hold the insulin pen device perpendicular to the client's skin to inject the medication