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A nurse is assisting with the plan of care for a client following a
transurethral resection of the prostate. Which of the following interventions
should the nurse include in the plan of care?
The nurse should irrigate the bladder using strict sterile technique and maintain closed
catheter drainage system to minimize the rick of infection.
A nurse is reviewing a client's electronic medical record and finds that an
assistive per sonnel recorder the client's temperature as 35.3 degrees Celsius
(95.5 degrees F) 2 hrs earlier. Which of the following actions should the nurse
take firsT?
check the clients temp
A nurse is receiving change-of-
shift report for four clients. Which of the following clients should the nurse see
first?
A client whose urinary output was 100mL for the past 12 hrs
A home health nurse is caring for a child who has Lyme disease. Which of the
following is an appropriate action for the nurse to take?
Ensure the state health department has been notified.
A nurse is caring for a client who has a vented NG tube set to low intermittent
suction and has vomited. Which of the following actions should the nurse
perform first?
Evaluate functioning of the suction device.
A client who has a diagnosis of complete placenta previa is admitted to the labor
and delivery suite
at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration.
Which of the
following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
Prepare the client for a cesarean section
A nurse enters a client's room and finds the client lying on the floor in a puddle of
water. Which of
the following statements should the nurse document in an incident report?
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,A. Client fell out of bed because an assistive personnel left the rails of the bed
down
B. Client's roommate thinks the client is confused and fell when getting out of
bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Client found lying on the floor near the bedside table
A charge nurse on a pediatric unit is making assignments for a float nurse from
the medical unit.
Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory
treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular
septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement
of a Herrington rod
A 10-year-old client who has pneumonia and is receiving respiratory treatments
A nurse is preparing to administer vancomycin to a client who has an infected
wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
Ototoxicity
A nurse is assessing an infant who has water intoxication. Which of the following
findings should the
nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
Generalized edema
A home health nurse is conducting an initial home visit for a client who has
terminal breast cancer.
The client has two school-age children and a limited support system. Which of
the following is the
priority nursing action?
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,A. Inform the client of available community resources
B. Assist the client in finding childcare options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
Inform the client of available community resources
A nurse in an emergency department is assessing a client who has a nasal
fracture. Which of the
following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry
Clear fluid drainage from the nares
A nurse in an urgent care clinic is collecting admission history from a client who
is at 16 weeks of
gestation and has bacterial vaginosis. The nurse should recognize that which of
the following clinical
findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria
Profuse milky white discharge
A nurse is discussing the z-track administration of hydroxyzine with a newly
licensed nurse. Which
of the following statements indicates the newly licensed nurse understands the
purpose of the
technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
This technique decreases the risk of subcutaneous infiltration
10. A nurse is caring for a full-term newborn immediately following birth. Which of
the following
actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn's eyes
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, B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn
Dry the newborn
A nurse is planning to provide community education about viral hepatitis. Which
of the following
should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
D. Clients who have a history of viral hepatitis are unable to donate blood
Clients who have a history of viral hepatitis are unable to donate blood
A nurse in a residential mental health facility is planning care for a new client who
has obsessive
compulsive disorder. Which of the following is appropriate for the nurse to
include in the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts
Gradually decrease the time allowed for ritualistic behavior
A nurse is assessing an adult male who has a BMI of 20. The nurse should
identify that the client's
BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity
Healthy weight
A nurse is caring for a client who is nulliparous and in the first stage of labor. The
last internal
assessment revealed 100% cervical effacement with 5 cm of dilation. At the end
of the last
contraction, the nurse observes a large gush of fluid coming out of the client's
perineal area. Which of
the following is a priority action by the nurse?
A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid
Check the FHR
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