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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 - KEY TERM 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 - KEY TERM 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 - KEY TERM 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 - KEY TERM 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 - KEY TERM 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 - KEY TERM 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 - KEY TERM 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 - KEY TERM 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 - KEY TERM This technique
decreases the risk of subcutaneous infiltration
10. A nurse is caring for a full-term newborn immediately following birth. Which of the
following
actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn's eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn - KEY TERM Dry the newborn
A nurse is planning to provide community education about viral hepatitis. Which of the
following
, should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
D. Clients who have a history of viral hepatitis are unable to donate blood - KEY TERM
Clients who have a history of viral hepatitis are unable to donate blood
A nurse in a residential mental health facility is planning care for a new client who has
obsessive
compulsive disorder. Which of the following is appropriate for the nurse to include in the
plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts - KEY TERM Gradually
decrease the time allowed for ritualistic behavior
A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that
the client's
BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity - KEY TERM Healthy weight
A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal
assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the
last
contraction, the nurse observes a large gush of fluid coming out of the client's perineal
area. Which of
the following is a priority action by the nurse?
A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid - KEY TERM Check the FHR
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 week