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A nurse is admitting a client who has
antisocial personality disorder. Which of
the following client behaviors should the
nurse identify as consistent with this dis-
order? C. Uses others for personal gain
A. Compulsive attention to details
B. Avoids interacting with others
C. Uses others for personal gain
D. Socially awkward in group situations
A nurse is interpreting the cardiac rhythm
strip of a client who was admitted with
syncope. Which of the following images
indicates that the client has atrial fibrilla-
tion?
A charge nurse on a pediatric unit is
making assignments for a float nurse
from the medical unit. Which of the fol-
lowing clients is appropriate to assign to
the float nurse?
A. A 10-year-old client who has pneu-
monia and is receiving respiratory treat-
A. A 10-year-old client who has pneu-
ments
monia and is receiving respiratory treat-
B. A 4-year-old client who has a Wilms
ments
tumor and is receiving chemotherapy
C. An 8-month-old client who is sched-
uled 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 Harrington rod
A nurse is assessing an infant who has
water intoxication. Which of the following
findings should the nurse expect? A. Generalized edema
A. Generalized edema
B. Elevated urine specific gravity
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C. Thready pulse
D. Increased hematocrit
A nurse is discussing the z-track ad-
ministration 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 This technique decreases the risk of sub-
sciatic nerve cutaneous infiltration
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 absorp-
tion rate of the drug
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?
A. Encourage the client to gain 2.3 kg per
C. Monitor the client for 1 hr after meals
week
B. Weigh the client once per week
throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
A nurse is planning care for a child
who has increased intracranial pressure
with a decrease in level of conscious-
ness. Which of the following interven-
tions should the nurse include in the plan
B. Maintain the head at a midline position
of care?
A. Perform active range-of-motion exer-
cises
B. Maintain the head at a midline position
C. Suction the airway frequently
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D. Perform neurological checks every 4
hrs
10. A nurse is assessing a client who has
delirium due to a febrile illness. Which of
the following findings should the nurse
expect?
A. Hallucinations
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
A nurse is assessing a client who is re-
ceiving enteral feedings via a gastrosto-
my tube. The nurse should identify that
which of the following findings indicates
fluid overload? D. Bounding pulses
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
A nurse is caring for a client following an
open colectomy. Which of the following
findings places the client at risk for de-
layed wound healing?
B. Hyperemesis
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
A home health nurse is reviewing treat-
ment goals with a client who has dia-
betes mellitus. The nurse should eval-
uate which of the following laboratory
B. HbA1c
tests to determine effective long-term
management of blood glucose levels?
A. 3-hr oral glucose tolerance test
B. HbA1c
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C. Fasting blood glucose test
D. Urinalysis for ketones
A nurse is caring for a client who has
neutropenia due to HIV. Which of the fol-
lowing precautions should the nurse take
while caring for this client?
A. Wear an N95 respirator
D. Use a dedicated stethoscope
B. Insert an indwelling urinary catheter to
monitor urinary output
C. Monitor the client's vital signs every 8
hr
D. Use a dedicated stethoscope
A nurse is caring for a client who reports
difficulty falling asleep at night. Which of
the following actions should the nurse
take?
A. Encourage the client to ambulate in
the hallway 1 hr before bedtime C. Schedule routine care tasks during
B. Tell the client to avoid drinking fluids 1 hours when the client is awake
hr before bedtime
C. Schedule routine care tasks during
hours when the client is awake
D. Advise the client to leave the television
in the room on when trying to fall asleep
A nurse is planning care for a newborn
who has hyperbilirubinemia and is to re-
ceive phototherapy. Which of the follow-
ing interventions should the nurse in-
clude?
A. Clothe the newborn in light cotton D. Place the newborn 45 cm (18 in) from
B. Check the newborn's temperature the light source
every 8 hrs. (every 4)
C. Administer 120 mL of water between
feedings
D. Place the newborn 45 cm (18 in) from
the light source