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Practice Questions and In-Depth Rationales
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk
for acquiring urinary tract infections. Which of the following actions should the nurse
include in the client's plan of care? ✔✔ Obtain a order for an in and out catheter
A nurse is planning care for a child who has suspected epiglottis. Which of the following
actions should the nurse take? ✔✔ Place the child on droplet precautions
A nurse is instructing a group of clients regarding calcium rich food. Which of the
following should the nurse include in the teaching as the best source of calcium? ✔✔ 1
cup of milk
A nurse is completing an admission assessment on an adolescent child who is a
vegetarian. He eats milk products but does not like beans. Which of the following items
should the nurse suggest the client order for lunch to provide nutrients most likely to be
lacking in his diet? ✔✔ Peanut Butter and Jelly Sandwich
A nurse is caring for a 1-month old infant who weighs 3540 g and is prescribed a dose
of cefazolin 50mg/kg IV bolus TID. How many mg should the nurse administer per
dose? ✔✔
A nurse is preforming a pre-college assessment on an adolescent. Which of the
following immunizations should the nurse anticipate administering? ✔✔ Meningococcal
polysaccharide vaccine
A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect? ✔✔ Nocturia at night
, A nurse is caring for a client who has active TB and is to be started on IV rifampin
therapy. The nurse should instruct the client that this medication can cause which of the
following adverse effects? ✔✔ Body sections turning a red orange color
A nurse is caring for a 6-week-old infant who as a pyloric stenosis. Which of the
following manifestations should the nurse expect? ✔✔ Projectile vomiting
A nurse receives a call from a parent of a child who has von Willebrand disease and
has having a nosebleed. Which of the following instructions should the nurse give to the
parents? ✔✔ "Have your child sit with her head tilted forward and hold pressure on her
nose for 10 minutes."
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings
should the nurse expect? ✔✔ Pain
A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to
a client who is scheduled for surgery in the morning. Which of the following actions
should the nurse include in the demonstration? ✔✔ Place her hands on the sides of her
rib cage
A nurse is planning care for a client who has idiopathic thrombocytopenic purpur (ITP)
Which of the following manifestations is the most appropriate for the nurse to monitor?
✔✔ Bleeding
A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following
findings should the nurse expect? (select all that apply). ✔✔ -Hypotension
-Weak pulses
-Murmur
.
A nurse is providing teaching to a parent of a child who has Hirschsprung disease is
scheduled for initial surgery. Which of the following statements indicates an
understanding of the teaching? ✔✔ I'm glad that my child's ostomy is only temporary
A school nurse identifies that a child has pediculosis capitis and educates the child's
parents about the condition. Which of the following statements by the parents indicated