2020 || ACTUAL EXAM WITH
VERIFIED SOLUTIONS || NEW!!!
NEW!!! NEW!!!
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 - ANS✔✔-b) Oliguria
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 - ANS✔✔-c) A client with indications of
hypovolemic shock
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 -
ANS✔✔-c) A client whose chronic kidney disease with cloudy diasylate outflow
A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the
following food selections indicates that client understands teaching?
a) A sandwich and milkshake
b) Rice with black beans
c) Cottage cheese and tuna lettuce
d) Three egg omelette with low-sodium ham - ANS✔✔-b) Rice with black beans
A nurse is planning care for client sealed radiation implant and is to remain in the hospital for
1 week. Which of the following should the nurse include in the plan of care?
a) Remove dirty linens from the room after double bagging.
b) Wear a dosimeter film badge while in the client's room
c) Limit each of the clients is yours to one hour per day.
d) Ensure family members remain at least 3 feet from the client - ANS✔✔-b) Wear a
dosimeter film badge while in the client's room
A nurses for Caring for four clients. Which of the following client should the nurse care for
first?
a) A client to receive a chemotherapy treatment or first national
b) A client who has an appendectomy to these don't has diminished all sounds
c) A client is hypothyroidism and his stuporous
d) A client who is a burn requiring a sterile dressing change - ANS✔✔-c) A client is
hypothyroidism and his stuporous
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 - ANS✔✔-c) Provide standby assist with the client
from bed
A nurse is caring for a client who is in labor and his seat 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 - ANS✔✔-d) Head Compression
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 - ANS✔✔-a) glomerular filtration rate of 14 mL/ minute
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The
following is an appropriate action for the nurse to take?
a) Placed infant under radiant warmer
b) Move the probe site every 3 hours
c) Heat the skin one minute prior to placing the program
d) Placed a sensor on the index finger - ANS✔✔-c) Heat the skin one minute prior to placing
the program
A nurse in a mental health facility receives a change of shift report on for clients. Which of
the following clients should the nurse plan to assess first?
a) Client placed in restraints to the aggressive behavior
, b) A new limited client pleasures history of 4.5 kg weight loss in the past two months
c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
d) Applied he'll be receiving his first ECT treatment today - ANS✔✔-a) Client placed in
restraints to the aggressive behavior
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of
nonpharmacological pain management. Which of the following statements by the nurse is an
appropriate description of the use of hypnosis during labor?
a) Hypnosis focuses on the biofeedback as a relaxation technique
b) Hypnosis promotes increased control of her pain perception during contractions
c) Hypnosis uses therapeutic touch to reduce anxiety during labor
d) Hypnosis provides instruction to minimize pain - ANS✔✔-b) Hypnosis promotes increased
control of her pain perception during contractions
A nurse in a County Jail health clinic is leading group therapy session. A client who was
incarcerated for theft is addressing the group. Which of the following is an example of
reaction formation? (rxn formation is when you use opposite feelings; ex: being super nice to
someone you dislike)
a) I steal things because it's the only way I can keep my mind off my bad marriage b) I can't
believe I was accused of something I didn't do
c) I don't want talk about my feelings right now. We will talk more next time
d) I think that people just you're just lazy and should earn money honestly - ANS✔✔-d) I
think that people just you're just lazy and should earn money honestly
A nurse is obtaining the medical history of a client who has a new prescription for isosorbide
monotitrate. Which of the following should the nurse identify as a contraindication to
medication?
a) Glaucoma
b) Hypertension
c) Polycythemia
d) Migraine headaches - ANS✔✔-a) Glaucoma