A child is having a generalized tonic-clonic seizure. Which action should the nurse
take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help.
Give this one a try later!
A
The first priority during a seizure is to provide a safe environment, so the
nurse should clear the area (A) to reduce the risk of trauma. The child
should not be restrained (B) because this may cause more trauma. Objects
should not be placed in the child's mouth (C) because it may pose a
choking hazard. Although (D) should be implemented after the seizure, the
nurse should not leave the child during a seizure to get help.
,The nurse calls the primary health care provider to report the status of a postsurgical
client. Place the statements in the correct SBAR communication format.
A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88,
HR 90, and RR 26, with an O2 sat of 95%."
B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital."
C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain
control with his current medication regimen since the surgery."
D. "Would you like to make a change in his pharmacologic regimen?"
A. C, B, A, D
B. B, C, A, D
C. A, B, C, D
D. A, C, D, B
Give this one a try later!
B
SBAR:
S = Situation and includes introduction of the nurse and client/setting (B).
B = Background and includes the presenting complaint and relevant history
(C).
A = Assessment and includes current vital signs and other information (A).
R = Recommendations and includes an explanation of why you are calling
or a suggestion about which action should be taken (D).
The nurse is preparing a client for surgical stabilization of a fractured lumbar
vertebrae. Which indication(s) best supports the client's need for insertion of an
indwelling urinary catheter? (Select all that apply.)
A.Hourly urine output
B.Bladder distention
C.Urinary incontinence
D.Intraoperative bladder decompression
E.Urine sample for culture
,Give this one a try later!
ABD
Continuous bladder drainage using an indwelling catheter is indicated for
monitoring hourly urinary output (A), bladder distention (B), and bladder
decompression (D) related to urinary retention under anesthesia. Less
invasive measures, such as a condom catheter or bladder training for
urinary incontinence (C) or midstream collection of urine for culture (E) are
not indicated based on the client's description.
The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis
measures to help reduce the pain associated with the disease. Which instruction
should the nurse provide to these parents?
A.Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to
getting the child out of bed in the morning.
B.Apply ice packs to edematous or tender joints to reduce pain and swelling.
C.Warm the child with an electric blanket prior to getting the child out of bed.
D.Immobilize swollen joints during acute exacerbations until function returns.
Give this one a try later!
C
Early morning stiffness and pain are common symptoms of rheumatoid
arthritis. Warming the child (C) in the morning helps reduce these
symptoms. Although moist heat is best, an electric blanket could also be
used to help relieve early morning discomfort. (A) on an empty stomach is
likely to cause gastric discomfort. Warm (not cold) packs or baths are used
to minimize joint inflammation and stiffness (B). (D) is contraindicated,
because joints should be exercised, not immobilized.
A client tells the nurse that he is suffering from insomnia. Which information is most
important for the nurse to obtain?
, A.The client's usual sleeping pattern
B.Whether the client smokes
C.How much liquid the client consumes before bedtime
D.The amount of caffeine that the client consumes during the day
Give this one a try later!
A
The first thing to determine is the client's usual sleeping pattern and how it
has changed to become what the client describes as insomnia (A). (B, C,
and D) provide additional information after (A) is ascertained.
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in
my breasts after the baby sucks for a few minutes?" Which information should the
nurse provide?
A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have good latch-on.
D.The infant is not positioned correctly.
Give this one a try later!
B
When the mother's milk comes in, usually 2 to 3 days after delivery, women
often report they feel a tingling sensation in their nipples (B) when let-down
occurs. (A, C, and D) provide inaccurate information.
The nurse is preparing assignments for the day shift. Which client should be assigned
to the staff RN rather than a PN?
A.A client with an admitting diagnosis of menorrhagia who is now 24 hours post-
vaginal hysterectomy
take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help.
Give this one a try later!
A
The first priority during a seizure is to provide a safe environment, so the
nurse should clear the area (A) to reduce the risk of trauma. The child
should not be restrained (B) because this may cause more trauma. Objects
should not be placed in the child's mouth (C) because it may pose a
choking hazard. Although (D) should be implemented after the seizure, the
nurse should not leave the child during a seizure to get help.
,The nurse calls the primary health care provider to report the status of a postsurgical
client. Place the statements in the correct SBAR communication format.
A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88,
HR 90, and RR 26, with an O2 sat of 95%."
B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital."
C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain
control with his current medication regimen since the surgery."
D. "Would you like to make a change in his pharmacologic regimen?"
A. C, B, A, D
B. B, C, A, D
C. A, B, C, D
D. A, C, D, B
Give this one a try later!
B
SBAR:
S = Situation and includes introduction of the nurse and client/setting (B).
B = Background and includes the presenting complaint and relevant history
(C).
A = Assessment and includes current vital signs and other information (A).
R = Recommendations and includes an explanation of why you are calling
or a suggestion about which action should be taken (D).
The nurse is preparing a client for surgical stabilization of a fractured lumbar
vertebrae. Which indication(s) best supports the client's need for insertion of an
indwelling urinary catheter? (Select all that apply.)
A.Hourly urine output
B.Bladder distention
C.Urinary incontinence
D.Intraoperative bladder decompression
E.Urine sample for culture
,Give this one a try later!
ABD
Continuous bladder drainage using an indwelling catheter is indicated for
monitoring hourly urinary output (A), bladder distention (B), and bladder
decompression (D) related to urinary retention under anesthesia. Less
invasive measures, such as a condom catheter or bladder training for
urinary incontinence (C) or midstream collection of urine for culture (E) are
not indicated based on the client's description.
The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis
measures to help reduce the pain associated with the disease. Which instruction
should the nurse provide to these parents?
A.Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to
getting the child out of bed in the morning.
B.Apply ice packs to edematous or tender joints to reduce pain and swelling.
C.Warm the child with an electric blanket prior to getting the child out of bed.
D.Immobilize swollen joints during acute exacerbations until function returns.
Give this one a try later!
C
Early morning stiffness and pain are common symptoms of rheumatoid
arthritis. Warming the child (C) in the morning helps reduce these
symptoms. Although moist heat is best, an electric blanket could also be
used to help relieve early morning discomfort. (A) on an empty stomach is
likely to cause gastric discomfort. Warm (not cold) packs or baths are used
to minimize joint inflammation and stiffness (B). (D) is contraindicated,
because joints should be exercised, not immobilized.
A client tells the nurse that he is suffering from insomnia. Which information is most
important for the nurse to obtain?
, A.The client's usual sleeping pattern
B.Whether the client smokes
C.How much liquid the client consumes before bedtime
D.The amount of caffeine that the client consumes during the day
Give this one a try later!
A
The first thing to determine is the client's usual sleeping pattern and how it
has changed to become what the client describes as insomnia (A). (B, C,
and D) provide additional information after (A) is ascertained.
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in
my breasts after the baby sucks for a few minutes?" Which information should the
nurse provide?
A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have good latch-on.
D.The infant is not positioned correctly.
Give this one a try later!
B
When the mother's milk comes in, usually 2 to 3 days after delivery, women
often report they feel a tingling sensation in their nipples (B) when let-down
occurs. (A, C, and D) provide inaccurate information.
The nurse is preparing assignments for the day shift. Which client should be assigned
to the staff RN rather than a PN?
A.A client with an admitting diagnosis of menorrhagia who is now 24 hours post-
vaginal hysterectomy
