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A nurse is assessing a client who has received an antibiotic. The nurse should
identify which of thefollowing findings as an indication of a possibleallergic reaction
to the medication?
A. Bradycardia
B. Headache
C. Joint pain
D. Hypotension
nurse on a mental health unit is caring for a client who has schizophrenia and is
experiencingauditory hallucinations telling them tohurt others. The client is
refusing to take anti-psychoticmedication. Which of the following responses
should the nurse make?
A. “You should plan to take this medication for a few weeks.”
B. “You will regret it if you do not take this medication.”
C. “This medication will help you respond to the voices.
D. “This medication will help you stop the voices you are hearing.”
A nurse is providing care for a patient who has depression and is to have
electroconvulsive therapy.Which of the following conditions should the
nurse identify as increasing the client’s risk for complications?
A. Hyperthyroidism
B. Renal calculi
C. Diabetes mellitus
D. Cardiac dysrhythmias
A nurse is reviewing the laboratory results of a client who has rheumatoid
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arthritis. Which of thefollowing findings should the nurse report to the
provider?
A. WBC count 8,000/mm
B. Platelets 150,000/mm
C. Aspartate aminotransferase
10 units/LD. Erythrocyte
sedimentation 75 mm/hr
A nurse is caring for a client who has a tension pneumothorax. Which ofthe
followingmanifestations should the nurse expect?
A. Paradoxical chest movement
B. Bilateral crackles
C. Asymmetry of the chest
D. Blood-tinged sputum
A nurse is caring for a client who is at 11 weeks of gestation. Which ofthe
followingimmunizations should the nurse recommend?
A. Human
papillomavirusB. Influenza
C. Measles, mumps and rubella
D. Varicella
A nurse in a pediatric clinic is reviewing the laboratory test results of a school-
age child.Which of the following findings should the nurse report tothe
provider?
A. Hct 40%
B. Hgb 12.5 g/dL
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C. Platelets
250,000/mmD. WBC
14,000/mm
A nurse is assessing a client who is receiving packed RBCs. Which of the
followingindicates fluid overload?
A. Low-back pain
B. Thready pulse
C. Hypotensi
onD.
Dyspnea
A nurse is preparing to administer betamethasone to a client who is 25 weeks
of gestation and has preterm labor. Which of the following findings should the
nurse identify as an adverse effect of thismedication?
A. Hyperglycemia
B. Uterine contractions
C. Proteinuria
D. Hypotension
A nurse is preparing to obtain a blood sample from a client who has a central
venous catheter. Whichof the following actions should the nurse take? (SATA)
B. Access the catheter using a large bore needle.
A. Apply a tourniquet above the catheter insertion site.
C. Aspirate for blood return to access catheter patency.
D. Flush the catheter with 0.9% sodium chloride.
E. Apply force when resistance is met while flushing the catheter.