1, 2, 3, 4) With Questions And Revised
Correct Answers & Rationales ()
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1) A nurse in an emergency department completes an assessment on an
adolescent client that has conduct
disorder. The client threatened suicide to teacher at school. Which of the
following statements should the
nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
c) Tell me how often do you drink alcohol
d) Tell me about your school schedule - CORRECT ANSWER- C) tell me how often
do you drink alcohol
2) *A nurse is observing bonding to the client her newborn. Which of following
actions by the client requires
the nurse to intervene?
a) Holding the newborn in an en face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
,d) Viewing the newborn's actions to be uncooperative - CORRECT ANSWER- d)
Viewing the newborn's actions to be uncooperative
3) A nurse is caring for client who is taking levothyroxin. Which of the following
findings should indicate that
the medication is effective?
a) Weight loss (this drug acts as T4 and will normalize the effects of
hypothyroidism)
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation - CORRECT ANSWER- a) Weight loss (this drug acts as
T4 and will normalize the effects of hypothyroidism)
4) A nurse is planning discharge teaching for cord care for the parent of a
newborn. Which instructions would
you include in the teaching?
a) Contact provider if the cord still turns black (it's going to turn black)
b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH
cleanser)
c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent
infection)
d) The cord stump will fall off in five days (cord falls off in 10-14 days) - CORRECT
ANSWER- c) Keep the cord dry until it falls off (cord should be kept clean and dry
to prevent infection)
5) A nurse is assessing a client in the PACU. Which of the following findings
indicates decreased cardiac output?
,a) Shivering
b) Oliguria
c) Bradypnea
d) Constricted pupils - CORRECT ANSWER- b) Oliguria
6) A nurse is assisting with mass casualty triage: explosion at a local factory.
Which of the following client
should the nurse identify as the priority?
a) A client that has massive head trauma
b) A client has full thickness burns to face and trunk
c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity - CORRECT ANSWER- c) A
client with indications of hypovolemic shock
7) A nurse is a receiving report on four clients. Which of the following clients
should the nurse assess first?
a) A client who has illeal conduit and mucus in the pouch
b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged urine in
the bag - CORRECT ANSWER- c) A client whose chronic kidney disease with cloudy
diasylate outflow
8) A nurse is caring for a client just received the first dose of lisinopril. The
following is an appropriate nursing
intervention?
, a) Place's cardiac monitoring
b) Monitor the clients oxygen saturation level
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium - CORRECT ANSWER- c) Provide standby
assist with the client from bed
9) A nurse is caring for a client who is in labor and is receiving electronic fetal
monitoring. The nurse is reviewing the monitor tracing and notes early
decelerations. Which the following should the nurse
expect?
a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
d) Head Compression - CORRECT ANSWER- d) Head Compression
10) A nurse is caring for a client who has chronic kidney disease. The nurse should
identify which of the
following laboratory values as in an indication for hemodialysis?
a) glomerular filtration rate of 14 mL/ minute
b) BUN 16 mg/DL
c) serum magnesium 1.8 mg mg/dl
d) Serum phosphorus 4.0 mg/dL - CORRECT ANSWER- a) glomerular filtration rate
of 14 mL/ minute
11) A nurse is caring for an infant who has a prescription for continuous pulse
oximetry. The following is an