RN EXIT EXAM NEW 2023

RN EXIT EXAM NEW 2023 1. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? D) Liver enzymes (AST and ALT) 2. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk 3. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? B) Stimulates hydrochloric acid production 4. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention 5. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? C) "Keep in mind that for the age this is a normal response to being in the hospital." 6. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug? C) Prothrombin time 7. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? D) Increased restlessness 8. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of injury. The appropriate response by the nurse should be which of these statements? B) "In some instances the result is a retarded bone growth." 9. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? D) Tardive dyskinesia10. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? C) "Telangiectatic nevi are normal and will disappear as the baby grows." 11. A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? C) Monitor vital signs 12. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? B) Frequent neurovascular assessments of the affected leg 13. The nurse is teaching a client newly diagnosed with asthma how to use the metereddose inhaler (MDI). The client asks when they will know the canister is empty. The best response is A) Drop the canister in water to observe floating 14. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? A) Maintain good oral hygiene and dental care 15. A 7 month pregnant woman is admitted with complaints of painless vaginal bleedingover several hours. The nurse should prepare the client for an immediate B) Abdominal ultrasound 16. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? C) Decreased potassium 17. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? A) Potassium levels 18. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? C) Ineffective breathing patterns related to central nervous system depression 19. The nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to C) Reassess the child's temperature 20. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used toB) Measure forced expiratory volume 21. The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? C) Vastus lateralis 22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? B) Report hourly outputs of less than 30 ml/hr 23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? B) Strep throat went through all the children at the day care last month. 24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor 25. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint 26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia 27. The provisions of the law for the Americans with Disabilities Act require nurse managers to B) Provide reasonable accommodations for disabled individuals 28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? C) "I have diminished sexual function." 29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? D) ”I think I remember that standing cannot be done until after 72 hours." 30. Which statement best describes time management strategies applied to the role of a nurse manager? C) Set daily goals with a prioritization of the work31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? D) Abdominal mass and weakness 32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." 33. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will D) Improve team morale 34. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing 35. The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to D) Request an immediate private meeting with the health care provider and staff nurse 36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to C) Let’s discuss your decision to leave and then we can prepare you for discharge. 37. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? B) Heart murmur 38. A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to B) Maintain alveolar surface tension 39. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be C) Respiratory function 40. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?A) Hourly urine output 41. The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? A) Assume a decision-making role 42. A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has a high-pitched cry with exaggerated Moro reflex 43. A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make? b. This procedure determines if your baby has genetic or congenital disorders 44. A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain following the administration of oxycodone/acetaminophen. Which of the following actions should the nurse take first? a. Reposition the client 45. A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor? d. Chorioamnionitis 46. A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take? a. Administer oxygen via a face mask 47. A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction? c. Cover the newborn’s bladder with a sterile, non-adherent dressing 48. A nurse is reviewing the laboratory report of a client who is 24 hrs postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the following actions should the nurse take? c. Initiate IV access for isotonic solution with an 18-gauge catheter 49. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for sever preeclampsia. Which of the following findings should the nurse report to the provider? d. Urine output 20 mL/hr50. A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? d. Use an automatic puncture device on the heel 51. A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first? d. Assist the client to the bathroom 52. A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? b. Lentils 53. A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? a. Hemorrhage 54. A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concern about preparing her 2-year-old child for a new sibling. Which of the following is an appropriate response by the nurse? b. Require scheduled interactions between the toddler and the baby 55. A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The nurse should recognize that pregnancy is a contraindication to the administration of which of the following +medications? d. Isotretinoin 56. A nurse is reviewing the immunization status of a client who is pregnant. The nurse should inform the client that it is safe for her to receive which of the following immunizations during pregnancy? a. Tetanus 57. A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider? c. Fasting blood glucose 180 mg/dL 58. A nurse is caring for a client who is at 35 weeks of gestation and on bed rest due to severe preeclampsia. Which of the following is an appropriate action for the nurse to take? d. Keep the lights dimmed in the room 60. A nurse is caring for a client who is 2 days postpartum and states, “I want to continue breastfeeding, but my nipples are so sore.” Which of the following responses should the nurse make? b. Allow expressed milk to air dry on the nipples after feeding your infant 61. A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn’s mouth and nose. Identify the sequence the nurse should follow when performing suctionwith a bulb syringe. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Compress the bulb syringe Place the bulb syringe in newborn’s mouth Use bulb syringe to suction newborn’s nose Assess the newborn for reflex bradycardia 62. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who has hyporeflexia while receiving IV magnesium sulfate – hyporeflexia = absent??? c. A client who reports changing her perineal pad every 2 hours – heavy not extreme 63. A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching? b. Replace the diaphragm every 2 years 64. A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? d. Postpartum hemorrhage 65. A nurse is providing vehicle safety education to the parents of a premature newborn. Which of the following statements should the nurse include in the teaching? a. Your newborn will need to have a car seat test prior to discharge 66. A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? c. Allow the baby to feed at least every 3 hours 67. A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicates a complication? c. Hypotonic uterus 68. A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.) c. Labor induction with oxytocin d. History of uterine atony 69. The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? B) Use minimal physical contact 70. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism).Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets 71. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? C) HCT of 60 72. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? D) The affected child's age and weight 73. A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? B) Continue with the regular diet and include oral rehydration fluids 74. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? B) Adding a spacer device to the MDI canister 75. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? D) Whitish oval specks sticking to the hair 76. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? B) Water 77. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client’s history indicate a potential hazard for this test? B) Allergic to shellfish 78. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced 1 at a time beginning with cereal 79. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion?C) Limit the infusion time of each of the unit to a maximum of 4 hours 80. A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 -22. Based on this data, what is the first nursing action? C) Administer oxygen 81. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? D) I had a blood transfusion 15 years ago. 82. A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia 83. A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? C) Particulate respirator mask 84. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? C) The client’s urine output was 1500 cc in 5 hours 85. The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is 1/3 to 1/2 full 86. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? C) A decrease in lethargy 87. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? B) Whole milk is difficult for a young infant to digest 88. The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the postoperative period? A) Estrogen replacement therapy 89. The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls?A) Place nightlight in the bedroom 90. An 8 year-old client is admitted to the hospital for surgery. The child’s parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? C) Balloons 91. The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? C) Continue to monitor the client to see if the bubbling increases 92. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? B) Begin treatment with acyclovir at the onset of symptoms of recurrence 93. A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor for which of the following findings as an adverse effect? a. Decreased ability to bear down 94. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? b. Subconjunctival hemorrhage 95. A nurse is caring for a client who is 1 day postpartum following the birth of her first baby. The client’s partner states, “I’ve been having nightmares that we are homeless and the baby is starving.” Which of the following is an appropriate response by the nurse? b. I know you’re worried, but everything is going to be okay 96. A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings? b. The newborn has fewer than four wet diapers in 24 hr 97. A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? a. The newborn is beginning to cough b. The newborn’s respiratory rate is irregular c. The newborn’s pulse oximetry is 91% 98. A nurse is performing a physical examination of a term newborn upon admission to the nursery. In which order should the nurse perform the following assessments? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) – PUT THEM IN ORDER Observe the newborn’s respirationsAuscultate the newborn’s heart rate Auscultate the newborn’s abdomen Test the newborn’s reflexes 99. A nurse in a prenatal clinic is discussing quickening with a client who is in the first trimester of her first pregnancy. Which of the following statements by the client indicates understanding of the teaching? b. I will feel movement at about 16 to 20 weeks 100. A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider? c. Subconjunctival hemorrhage 101. A nurse is assessing a client who is in her second trimester for common physiological changes during pregnancy. The nurse notes a blotchy discoloration on the client’s forehead, nose, and cheeks. Which of the following changes should the nurse document? c. Chloasma 102. A nurse is conducting a class for a group of clients about birth control. Which of the following information should the nurse include in the teaching? a. You should have an annual examination to assess your diaphragm 103. A nurse is caring for a client who is in the first stage of labor and the fetal head is in a posterior position. The client reports pressure and pain in her lower back. Which of the following nonpharmacological comfort measures should the nurse suggest first? d. Counterpressure 104. A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse report to the provider? a. Urinary output 20 mL/hr 105. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. The nurse should monitor for which of the following adverse effects? d. Absence of deep tendon reflexes 106. A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include? a. Yellow exudate will form at the surgical site in 24 hours 107. A nurse is reviewing a client’s rubella titer of 1:8 at her second prenatal visit. Which of the following statements by the nurse is appropriate? d. During your third trimester, you will need to repeat a blood test for the titer108. A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take? d. Continue to monitor the client 109. A nurse in a postpartum unit is caring for several clients. Which of the following tasks should the nurse delegate to assistive personnel? c. Check the saturation of the perineal pad 110. A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching? b. Ovulation will remain the same 111. A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.) a. Administer 70% nitrous oxide mixed with oxygen e. Apply counterpressure to the sacral area 112. A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Nagele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.) 1215 113. A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) THIS QUESTION REQUIRES “EXHIBIT” HEARING, SO SINCE YOU CAN’T LISTEN, USE YOUR BEST JUDGMENT TO ANSWER THIS, POSSIBLY. c. Administer ceftriaxone IM 114. A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? d. Allow the baby to feed at least every 3 hr 115. A nurse is assessing a client who is 1 hr postpartum. The nurse notes a large amount of vaginal bleeding with several large blood clots on the client’s peripad. The client’s blood pressure is 70/42 mm Hg and her heart rate is 150/min. Which of the following actions should the nurse take first? c. Elevate the legs 116. A nurse is assisting the provider to administer a dinoprostone (Cervidil) insert to induce labor for a client. Which of the following actions should the nurse take? d. Verify that the informed consent is obtained prior to administratin117. A nurse is planning care for a newborn who is large for gestational age due to maternal gestational diabetes mellitus. The nurse should recognize that the newborn is at risk for which of the following conditions? (Select all that apply.) a. Hyperbilirubinemia e. Hypoglycemia 118. A nurse is providing prenatal teaching to a group of clients who are in their third trimester of pregnancy. Which of the following statements by a client indicates an understanding of the teaching? d. Once my water has broken, I will not be able to have epidural anesthesia 119. A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? c. Transmission can occur via the saliva and urine of the newborn 120. A nurse is assessing a postpartum client who is receiving oxytocin 1 hr. after a normal spontaneous delivery. During the assessment, the nurse notes that the client perineal pad is fully saturated. which of the following actions should the nurse anticipate taking? D. Massage the uterus until firm 121. A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself which statement by the clients indicates an understanding of the teaching? A. I will check my urine for protein only 122. A nurse is assessing a client and observes the umbilical cord protruding from the vaginal , after calling D. Apply upward pressure against the presenting part. 122. A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes mellitus. Which of the following report to the provider? C. BUN 25 mg/dL 123. A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labour A. A client who has gestational diabetes mellitus 124. A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following A. Allow the baby to feed at least every 3 hr. 125. A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. D. Sharp pelvic pain 126. A nurse is providing education about RH(D) immune globulin to a client who ispregnant. What indicate for administering RH(D)immune globulin? C. The client had a spontaneous abortion 127. A nurse is providing teaching to a client who is 2 days postpartum. C. You should have your provider refit you for a new diaphragm 128. A nurse is caring for a client who is 12hr. postpartum and has a fourth degree laceration of the perineum C. Provide the client with a cool sitz bath 129. A nurse is assessing four newborns. Which of the following clinical findings… A. A 2 day old infant who is excreting a thin, white discharge from both nipples 130 .A nurse is performing an initial assessment of a new born who was delivered with a nuchal cord. B. Facial petechiae 131. A nurse is assisting the provider to administer a dinoprostone insert to induce labor B. Place the client in a semi fowler position for 1 hr. after administration. 132. A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expected? A. malodorous 133. A nurse is teaching a group of women who are pregnant about actions to take if they are suspect they are experiencing preterm labor the nurse provides. c. empty your bladder 134. A nurse is admitting a client to the birthing unit who reports her contraction started 1hrs. ago. The nurse determine realizes that the client is at risk for which of the following conditions. D. postpartum hemorrhage. 135. A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the c. I should avoid becoming pregnant for at least 1 month following the immunization 136. A nurse is caring for a newborn who is 2 days old. Which of the following finding should the nurse report. A. Edema of the scalp that crosses lines 137. Teaching a client and her partner about the techniques of counter pressure during labor. Which of the following statement by the nurse is appropriate B.Your partner will apply steady pressure with a tennis ball to your lower back 138. A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth andwhose mother had hepatitis B. which intervention should the nurse include in the plan of care A. Administer hepatitis B immune globulin IM to the newborn 139. A nurse is caring for a client who has preeclampsia and receiving magnesium sulfate. Which of the following clinic? d. increased muscle weakness. 140. A nurse is creating a plan of care for a client who is in active labor and has mitral valve ster A. administer 500ml of 0.9% sodium chloride solution every hour 141. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." 142. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? B) Give information about advance directives 143. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to D) Administer diphenhydramine as ordered 144. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? B) A toddler with severe deep abrasions over 98% of the body 145. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to C) Notify the admissions office and wait to apply the bracelet 146. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? D) Call the provider for clarification 147. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: D) open the client's airway 148. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? D) Auscultate the lungs149. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? C) 72 year-old recovering from surgery after a hip replacement 2 hours ago 150. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? B) That was done correctly. Did you have any problems with the insertion? 151. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? C) contact precautions 152. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? B) clean the meatus, begin voiding, then catch urine stream 153. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? B) watermelon 154. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? C) Immediately wash the hands with vigor 155. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” 156. A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? B) Glascow Coma Scale 8, respirations regular 157. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? A) The statement of client rights and the client self determination act158. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN 159. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? B) Restlessness and increased mucus production 160. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? C) "Clothes are becoming tighter across her abdomen."