,After placing a 36-week gestation newborn in and isolette and drying the infant with
several blankets, what should the nurse implement next?
a. Administer the vitamin K injection
b. Remove the wet blankets and linens from the isolette
c. Place erythromycin ophthalmic ointment in both eyes
d. Open the isolate door to assess the infants' vital signs - CORRECT ANSWERS-c.
Place erythromycin ophthalmic ointment in both eyes
A client in the third trimester of pregnancy complaints of frequent nasal stuffiness and
occasional nosebleeds. Her chest circumference has increased by 5 cm during the
pregnancy, and she uses thoracic breathing. Her diaphragm is elevated, and she has
an increased costal angle. Which intervention should the nurse implement?
A. Ask a nurse with more experience to validate the costal angle finding
B. Ask the health care provider to evaluate the client's respiratory status
C. Examine the client for signs of tissue and anoxia, such as pallor
D. Record the respiratory finding in the client's record as normal - CORRECT
ANSWERS-C. Examine the client for signs of tissue and anoxia, such as pallor
A terminally ill male hospice client who is at home is showing decreased awareness of
his surroundings. His appetite is poor, and he often uses oral intake of solids and
liquids. For the past several days he has been unable to get out of bed. Which action
should the hospice nurse implement?
A. Ask family to remain nearby, but in another room
B. Encourage family to speak often with the client
C. Teach family how to assist the client to a wheelchair
D. Instruct family to offer client only soft bland foods - CORRECT ANSWERS-C. Teach
family how to assist the client to a wheelchair
A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy
tests and ultrasounds were negative, so an exploratory laparotomy was completed
during the night. When coffee ground material is observed in the drainage from the
nasal gastric tube, which intervention should the nurse implement?
a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage
c. Listen for evidence of diminished bowel sounds
d. Irrigate the nasogastric tube with water until clear - CORRECT ANSWERS-a. Verify
correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis who
reports that the abdominal pain is not as severe as it was on admission. Which
laboratory test should the nurse review to evaluate the client's clinical recovery?
a. Lipase
b. Creatinine
c. Bilirubin
d. Glucose - CORRECT ANSWERS-a. Lipase
,While assessing a client who had a laparotomy the previous day, the nurse notices that
300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which
action should the nurse take first?
a. Determine the client's vital signs
b. Monitor urinary output hourly
c. Notify the surgeon immediately
d. Assess the client's level of pain - CORRECT ANSWERS-b. Monitor urinary output
hourly
The nurse is reviewing the recommended preventative care for clients with asthma,
chronic bronchitis, and emphysema. Which healthcare measure is most important for
the nurse to recommend to these clients?
a. Ensure supplemental oxygen and respiratory medications are available at all times
b. Use nasal or cough tissues followed by hand washing at all times
c. Get annual flu and pneumococcal vaccine polyvalent vaccines
d. Avoid large crowded areas during the colder months of the year - CORRECT
ANSWERS-d. Avoid large crowded areas during the colder months of the year
A mother of a one-month-old infant calls the clinic to report that the back of her infant's
head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and active
b. Turn the infant on the left side braced against the crib when sleeping
c. Prop the infant in a sitting position with a cushion when not sleeping
d. Place a small pillow under the infants head while lying on the back - CORRECT
ANSWERS-a. Position the infant on the stomach occasionally when awake and active
A woman is brought to the labor and delivery unit after delivering a term infant and the
placenta in the hospital parking lot 10 minutes ago. Which action should the nurse
perform first?
a. Inspect the perineum for lacerations
b. Collect specimen for hemoglobin and hematocrit
c. Massage the fundus and give oxytocic agent
d. Place the infant to breast for bonding - CORRECT ANSWERS-c. Massage the
fundus and give oxytocic agent
A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam for nosocomial pneumonia. The nurse should report which
laboratory finding to the health care provider before administering the prescribed dose?
a. Elevated white blood cell count
b. Presence of gram-positive bacteria in the sputum
c. Decrease creatinine clearance
d. Elevated cholesterol and lipoproteins - CORRECT ANSWERS-b. Presence of gram-
positive bacteria in the sputum
A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing
and has a severe headache along with nausea. Her arterial blood gases are: ph 7.50;
, paco2 30 mmhg; HCO3 24 meq/L. Which assessment finding warrants immediate
intervention by the nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath - CORRECT ANSWERS-d. Fruity breath
When performing postural drainage on a client with chronic obstructive pulmonary
disease, which approach should the nurse use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals - CORRECT ANSWERS-a. Explain
that the client may be placed in five positions
A young male client with testicular cancer has a living will that describes his desire that
no extraordinary measures be taken to save his life. The health care provider knows the
client has a good prognosis and refuses to write a "do not resuscitate" (DNR)
prescription. Which action should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
D. Ask the family to review options with the client - CORRECT ANSWERS-A. Initiate an
Ethics Committee review of the case
In observing a client's face, which assessment finding requires the most immediate
intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted - CORRECT ANSWERS-b. Oral mucosa is cyanotic
The nurse is assessing a client with cirrhosis and notes that the client has a positive
Babinski reflex. Which action should the nurse take in response to the finding?
a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment - CORRECT ANSWERS-d. Complete
a thorough neurological assessment
Which action should the nurse take first after obtaining a urine specimen for culture and
sensitivity from an indwelling urinary catheter?
a. Ensure that the drainage bag is attached to the bed frame
b. Ensure continued sterility of the specimen container
c. Securely fasten the clamp on the drainage bag
several blankets, what should the nurse implement next?
a. Administer the vitamin K injection
b. Remove the wet blankets and linens from the isolette
c. Place erythromycin ophthalmic ointment in both eyes
d. Open the isolate door to assess the infants' vital signs - CORRECT ANSWERS-c.
Place erythromycin ophthalmic ointment in both eyes
A client in the third trimester of pregnancy complaints of frequent nasal stuffiness and
occasional nosebleeds. Her chest circumference has increased by 5 cm during the
pregnancy, and she uses thoracic breathing. Her diaphragm is elevated, and she has
an increased costal angle. Which intervention should the nurse implement?
A. Ask a nurse with more experience to validate the costal angle finding
B. Ask the health care provider to evaluate the client's respiratory status
C. Examine the client for signs of tissue and anoxia, such as pallor
D. Record the respiratory finding in the client's record as normal - CORRECT
ANSWERS-C. Examine the client for signs of tissue and anoxia, such as pallor
A terminally ill male hospice client who is at home is showing decreased awareness of
his surroundings. His appetite is poor, and he often uses oral intake of solids and
liquids. For the past several days he has been unable to get out of bed. Which action
should the hospice nurse implement?
A. Ask family to remain nearby, but in another room
B. Encourage family to speak often with the client
C. Teach family how to assist the client to a wheelchair
D. Instruct family to offer client only soft bland foods - CORRECT ANSWERS-C. Teach
family how to assist the client to a wheelchair
A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy
tests and ultrasounds were negative, so an exploratory laparotomy was completed
during the night. When coffee ground material is observed in the drainage from the
nasal gastric tube, which intervention should the nurse implement?
a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage
c. Listen for evidence of diminished bowel sounds
d. Irrigate the nasogastric tube with water until clear - CORRECT ANSWERS-a. Verify
correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis who
reports that the abdominal pain is not as severe as it was on admission. Which
laboratory test should the nurse review to evaluate the client's clinical recovery?
a. Lipase
b. Creatinine
c. Bilirubin
d. Glucose - CORRECT ANSWERS-a. Lipase
,While assessing a client who had a laparotomy the previous day, the nurse notices that
300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which
action should the nurse take first?
a. Determine the client's vital signs
b. Monitor urinary output hourly
c. Notify the surgeon immediately
d. Assess the client's level of pain - CORRECT ANSWERS-b. Monitor urinary output
hourly
The nurse is reviewing the recommended preventative care for clients with asthma,
chronic bronchitis, and emphysema. Which healthcare measure is most important for
the nurse to recommend to these clients?
a. Ensure supplemental oxygen and respiratory medications are available at all times
b. Use nasal or cough tissues followed by hand washing at all times
c. Get annual flu and pneumococcal vaccine polyvalent vaccines
d. Avoid large crowded areas during the colder months of the year - CORRECT
ANSWERS-d. Avoid large crowded areas during the colder months of the year
A mother of a one-month-old infant calls the clinic to report that the back of her infant's
head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and active
b. Turn the infant on the left side braced against the crib when sleeping
c. Prop the infant in a sitting position with a cushion when not sleeping
d. Place a small pillow under the infants head while lying on the back - CORRECT
ANSWERS-a. Position the infant on the stomach occasionally when awake and active
A woman is brought to the labor and delivery unit after delivering a term infant and the
placenta in the hospital parking lot 10 minutes ago. Which action should the nurse
perform first?
a. Inspect the perineum for lacerations
b. Collect specimen for hemoglobin and hematocrit
c. Massage the fundus and give oxytocic agent
d. Place the infant to breast for bonding - CORRECT ANSWERS-c. Massage the
fundus and give oxytocic agent
A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam for nosocomial pneumonia. The nurse should report which
laboratory finding to the health care provider before administering the prescribed dose?
a. Elevated white blood cell count
b. Presence of gram-positive bacteria in the sputum
c. Decrease creatinine clearance
d. Elevated cholesterol and lipoproteins - CORRECT ANSWERS-b. Presence of gram-
positive bacteria in the sputum
A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing
and has a severe headache along with nausea. Her arterial blood gases are: ph 7.50;
, paco2 30 mmhg; HCO3 24 meq/L. Which assessment finding warrants immediate
intervention by the nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath - CORRECT ANSWERS-d. Fruity breath
When performing postural drainage on a client with chronic obstructive pulmonary
disease, which approach should the nurse use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals - CORRECT ANSWERS-a. Explain
that the client may be placed in five positions
A young male client with testicular cancer has a living will that describes his desire that
no extraordinary measures be taken to save his life. The health care provider knows the
client has a good prognosis and refuses to write a "do not resuscitate" (DNR)
prescription. Which action should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
D. Ask the family to review options with the client - CORRECT ANSWERS-A. Initiate an
Ethics Committee review of the case
In observing a client's face, which assessment finding requires the most immediate
intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted - CORRECT ANSWERS-b. Oral mucosa is cyanotic
The nurse is assessing a client with cirrhosis and notes that the client has a positive
Babinski reflex. Which action should the nurse take in response to the finding?
a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment - CORRECT ANSWERS-d. Complete
a thorough neurological assessment
Which action should the nurse take first after obtaining a urine specimen for culture and
sensitivity from an indwelling urinary catheter?
a. Ensure that the drainage bag is attached to the bed frame
b. Ensure continued sterility of the specimen container
c. Securely fasten the clamp on the drainage bag
