A client who has a diagnosis of complete placenta previa is admitted to the labor
and delivery suite
at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration.
Which of the
following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam - CORRECT ANSWER-Prepare the client for a
cesarean section
,A nurse enters a client's room and finds the client lying on the floor in a puddle of
water. Which of
the following statements should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed
down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table - CORRECT ANSWER-
Client found lying on the floor near the bedside table
A charge nurse on a pediatric unit is making assignments for a float nurse from the
medical unit.
Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular
septal defect tomorrow
,D. A 14-year-old client who is scheduled for discharge today following placement
of a Herrington rod - CORRECT ANSWER-A 10-year-old client who has
pneumonia and is receiving respiratory treatments
A nurse is preparing to administer vancomycin to a client who has an infected
wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension - CORRECT ANSWER-Ototoxicity
A nurse is assessing an infant who has water intoxication. Which of the following
findings should the
nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit - CORRECT ANSWER-Generalized edema
A home health nurse is conducting an initial home visit for a client who has
terminal breast cancer.
The client has two school-age children and a limited support system. Which of the
following is the
priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding childcare options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis - CORRECT
ANSWER-Inform the client of available community resources
, A nurse in an emergency department is assessing a client who has a nasal fracture.
Which of the
following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry - CORRECT ANSWER-Clear fluid drainage from the
nares
A nurse in an urgent care clinic is collecting admission history from a client who is
at 16 weeks of
gestation and has bacterial vaginosis. The nurse should recognize that which of the
following clinical
findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria - CORRECT ANSWER-Profuse milky white discharge
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?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug - CORRECT
ANSWER-This technique decreases the risk of subcutaneous infiltration
and delivery suite
at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration.
Which of the
following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam - CORRECT ANSWER-Prepare the client for a
cesarean section
,A nurse enters a client's room and finds the client lying on the floor in a puddle of
water. Which of
the following statements should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed
down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table - CORRECT ANSWER-
Client found lying on the floor near the bedside table
A charge nurse on a pediatric unit is making assignments for a float nurse from the
medical unit.
Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular
septal defect tomorrow
,D. A 14-year-old client who is scheduled for discharge today following placement
of a Herrington rod - CORRECT ANSWER-A 10-year-old client who has
pneumonia and is receiving respiratory treatments
A nurse is preparing to administer vancomycin to a client who has an infected
wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension - CORRECT ANSWER-Ototoxicity
A nurse is assessing an infant who has water intoxication. Which of the following
findings should the
nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit - CORRECT ANSWER-Generalized edema
A home health nurse is conducting an initial home visit for a client who has
terminal breast cancer.
The client has two school-age children and a limited support system. Which of the
following is the
priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding childcare options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis - CORRECT
ANSWER-Inform the client of available community resources
, A nurse in an emergency department is assessing a client who has a nasal fracture.
Which of the
following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry - CORRECT ANSWER-Clear fluid drainage from the
nares
A nurse in an urgent care clinic is collecting admission history from a client who is
at 16 weeks of
gestation and has bacterial vaginosis. The nurse should recognize that which of the
following clinical
findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria - CORRECT ANSWER-Profuse milky white discharge
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?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug - CORRECT
ANSWER-This technique decreases the risk of subcutaneous infiltration
