ANSWERS UPDATED 2025 |WELL STRUCTURED|100% VERIFIED|
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? c) Tell me how often do you drink alcohol
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
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 face position
d) Viewing the newborn's actions to be uncooperative
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
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
a) Weight loss
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation
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 c) Keep the cord dry until it falls off
b) Clean the base of the cord with hydrogen peroxide daily
c) Keep the cord dry until it falls off
d) The cord stump will fall off in five days
A nurse is assessing a client in the PACU. Which of the following
findings indicates decreased cardiac output?
a) Shivering
b) Oliguria
b) Oliguria
c) Bradypnea
d) Constricted pupils
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 c) A client with indications of hypovolemic shock
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
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
c) A client whose chronic kidney disease with cloudy diasylate outflow
outflow
d) A client was transurethral resection of the prostate with a red
tinged urine in the bag
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
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium
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
d) Head Compression
tracing and notes early decelerations. Which the following should
the nurse expect?
, a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
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 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
A nurse is caring for an infant who has a prescription for continu-
ous pulse oximetry. The following is an appropriate action for the
nurse to take?
a) Placed infant under radiant warmer c) Heat the skin one minute prior to placing the program
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
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 a) Client placed in restraints to the aggressive behavior
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
A nurse working at the clinic is teaching a group of clients who are
pregnant on the use of non-pharmacological 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
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
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?
a) I steal things because it's the only way I can keep my mind off
my bad marriage d) I think that people just you're just lazy and should earn money
b) I can't believe I was accused of something I didn't do honestly
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
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 a) Glaucoma
b) Hypertension
c) Polycythemia
d) Migraine headaches
The nurses is caring for a client recovering from an acute myocar-
dial infarction. Which following
intervention should the nurse include in the point of care?
a) Draw a troponin level every four hours d) Obtain a cardiac rehabilitation consult
b) Performance EKG every 12 hours
c) Plant oxygen tent fell over minutes via rebreather mask
d) Obtain a cardiac rehabilitation consult
, A Nurses caring for client who has breast cancer and has been
covering receiving chemotherapy. Which of
the following laboratory values should nurse report to provider?
a) WBC 3,000/mm3 a) WBC 3,000/mm3
b) Hemoglobin 14 g/dl
c) Platelet 250,000/mm3
d) aPTT 30 seconds
Home health nurse is carefully planned for Alzheimer's disease.
To the following action should the nurse
include in the plan of care
a) Place a daily calendar in the kitchen a) Place a daily calendar in the kitchen
b) Replace button clothing with zippered items
c) Replace the carpet with hardwood floors
d) Create variation in daily routine
Nurse is performing change of shift assessments on 4 clients.
Which of the following findings should the
nurse report to provider first?
a) The client was cystic fibrosis and has a thick productive clock
and reports thirst
b) Client who has gastroenteritis and is lethargic and confused
b) Client who has gastroenteritis and is lethargic and confused
c) The Client has diabetes mellitus has morning fasting Legal cost
of 185 mg over deal
d) The client was sick of signing it reports pain 15 minutes after
receiving oral analgesic
A nurse is caring for a client was in the second trimester of
pregnancy and asks how to treat constipation.
Which of the following statements by the nurse is appropriate?
a) Decrease taking vitamins and supplements to every other day d) Drink hot water with lemon juice each morning when you wake
b) Eat 15 g of fiber per day up
c) Consume 48 ounces of water each day
d) Drink hot water with lemon juice each morning when you wake
up
A nurse is caring for a client who is preparing his advance direc-
tives. Which is the following statements by
the client indicates an understanding of advanced directives?
select all that apply
a) I can't change my instructions once a minute d) I have the right to refuse treatment
b) My doctor will need to approve my advance directives e) My health care proxy can make medical decisions for me
c) I need an attorney to witness my signature on the advance
directives
d) I have the right to refuse treatment
e) My health care proxy can make medical decisions for me
A nurse is caring for a client who is at 32 weeks gestation and has
a history of cardiac disease. Which of
the following positions should the nurse place the client to best
promote optimal cardiac output?
a) The chest d) Left lateral
b) Standing
c) Supine
d) Left lateral
A nurse is caring for a group of clients. Which of the following
clients should the nurse assign to an AP?
a) Client who has chronic obstructive pulmonary disease and
needs guidance on incentive spirometry
b) Client who has awoken following a bronchoscopy and requests d) Client who had a cerebrovascular accident two days ago and
a drink needs help toileting
c) Client who had a myocardial infarction 3 days ago reports chest
discomfort
d) Client who had a cerebrovascular accident two days ago and
needs help toileting