A nurse is assessing an infant who has water intoxication. Which of the following findings should the
nurse expect? - Answer-bounding pulse
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 -
Answer-a. This technique decreases the risk of subcutaneous infiltration
1. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan? - Answer-a. Monitor the client for 1 hr after meals
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving
the client to safety, which of the followings is the priority action? - Answer-a. Close the fire door on the
unit
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings
should the nurse expect? - Answer-a. Hallucinations
1. A nurse is caring for a client following an open colectomy. Which of the following findings places the
client at risk for delayed wound healing? - Answer-hyperemesis
1. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse
should evaluate which of the following laboratory tests to determine effective long-term management
of blood glucose levels? - Answer-A1C
1. A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions
should the nurse take while caring for this client? - Answer-a. Use a dedicated stethoscope
,1. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following
actions should the nurse take? - Answer-Tell the client to avoid drinking fluids 1 hr before bedtime
1. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy.
Which of the following interventions should the nurse include? - Answer-a. Place the newborn 45 cm
from the light source
1. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their
feelings. Which of the following referrals should the nurse make? - Answer-social worker
1. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is
receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which
of the following findings? - Answer-a. Contractions occur every 90 seocnds
1. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood
pressure. The nurse should identify that these findings are potential manifestations of which of the
following? - Answer-a. Opioid intoxication
1. A nurse is precepting a nursing student who brings the following client observations to the nurse's
attention. Which of the following clients should the nurse assess first? - Answer-a. A client who is
coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago
1. A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which
of the following statements should the nurse manager include in the teaching? - Answer-a. Include the
complete name of the medication morphine sulfate
1. A community health nurse is performing a vision screening on a 4 month old infant. When shining a
light source into the infant's visual field, which of the following is an expected finding? - Answer-the
infant closes their eyes
, 1. A nurse is teaching a client and their family about home hospice care. Which of the following
information should the nurse include in the teaching? - Answer-a. Hospice care improves quality of life
through palliative care
1. A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is
appropriate? - Answer-a. Use aseptic technique and drop the medication into the conjunctival sac
1. A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted
infections in the community. The purpose of which of the following is to generate new ideas to address
the public health concern? - Answer-a. A brainstorming session with nurses
1. A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure.
Which of the following information should the nurse include in the teaching? - Answer-a. Change clothes
after working in the field
1. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the
nurse take? - Answer-a. Monitor for abdominal ascites
1. A nurse is caring for a client who is receiving systematic desensitization therapy to treat agoraphobia.
Which of the following client statements should indicate to the nurse that the treatment has been
effective? - Answer-a. I was able to sit on a park bench for 30 minutes
1. A nurse is caring for a client who is receiving a blood transfusion at 125mL/hr and develops a
hemolytic reaction. Which of the following actions should the nurse perform? - Answer-a. Infuse 0.9%
sodium chloride IV
1. A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral
feedings at 65mL/hr through a gastrostomy tube. Which of the following findings requires immediate
intervention by the nurse? - Answer-a. The gastric residual volume is 250 mL following 2 hr of infusion