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1. A client who has a diagnosis of complete placenta previa is admitted to
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m the labor and delivery suite at 36 weeks gestation with contractions 5 min
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in frequency and 1 min in duration. Which of the following actions should
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m the nurse take?
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A. Rupture the amniotic sac m m m
B. Medicate the client for pain m m m m
C. Prepare the client for a cesarean section
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D. Perform a vaginal exam m m m
…Ans>> Prepare the client for a Cesarean section
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2. A nurse enters a client's room and finds the client lying on the floor in a
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m puddle of water. Which of the following statements should the nurse document
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1 m/ m71
, in an incident report?
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A. Client fell out of bed because an assistive personnel left the rails of the bed
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m down
B. Client's roommate thinks the client is confused and fell when getting out of
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m bed
C. Client appears to have slipped in water but reports no injuries
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D. Client found lying on the floor near the bedside table
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…Ans>> Client found lying on the floor near the bedside table
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3. A charge nurse on a pediatric unit is making assignments for a float
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m nurse from the medical unit. Which of the following clients is appropriate
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to assign to the float nurse?
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A. A 10-year-old client who has pneumonia and is receiving respiratory
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treatments
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B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
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C. An 8-month-old client who is scheduled for a surgical repair of a ventricular
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m septal defect tomorrowm m
D. A 14-year-old client who is scheduled for discharge today following
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placement of a Herrington rod
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…Ans>> m A 10-year-old client who has pneumonia and is receiving respiratory
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m treatments
4. A nurse is preparing to administer vancomycin to a client who has an
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2 m/ m71
,m infected wound. The nurse should plan to monitor for which of the
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m following adverse reactions?
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A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
…Ans>> Ototoxicity
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5. A nurse is assessing an infant who has water intoxication. Which of the
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m following findings should the nurse expect?
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A. Generalized edema m
3 m/ m71
, B. Elevated urine specific gravity m m m
C. Thready pulse m
D. Increased hematocrit m
…Ans>> Thready pulse mm m
6. A home health nurse is conducting an initial home visit for a client who
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m has terminal breast cancer. The client has two school-age children and a
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m limited support system. Which of the following is the priority nursing
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m action?
A. Inform the client of available community resources
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B. Assist the client in finding child care options
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C. Agree upon short-term goals for the client
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D. Ask the client about their understanding of the diagnosis
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…Ans>> Inform the client of available community resources
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7. A nurse in an emergency department is assessing a client who has a nasal
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m fracture. Which of the following findings should cause the nurse to suspect a
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m skull fracture? m
A. Clear fluid drainage from the nares
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B. Report of pain around the eyes m m m m m
C. Dried blood in the mouth m m m m
D. Mandibular asymmetry m
4 m/ m71