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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 - ANS :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
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C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table - ANS :Client found lying on the floor
near the bedside table
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 - ANS :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 - ANS :Client found lying on the floor
near the bedside table
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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 - ANS :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 - ANS :Ototoxicity
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the
nurse expect?
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A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit - ANS :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 - ANS :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
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