100% DETAILED VERIFIED ANSWERS)
A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite,
and lightheadedness. Which of these assessments should a nurse make? - Measure the
client's body temperature.
Which of these nursing measures is the priority for a child who has hemophilia and who
sustains a leg injury? - Administering the missing factor VIII to the child.
A client who has a history of asthma develops an acute asthma attack. Which of these
questions should a nurse ask when assessing the etiology of this attack? - "Have you eaten
any new foods recently?"
Which of these foods should a nurse suggest that a client who is diagnosed with iron-
deficiency anemia choose for dinner? - Cooked dry beans, green leafy vegetables, and dried
fruits.
A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8-months-
pregnant primarily to: - determine the fetal presentation.
A child is brought to the clinical for serum lead screening because of ingestion of lead-based
paint. Which of these manifestations, if present in the child, would indicate early signs of lead
toxicity? - Behavior changes.
A nurse should assist a pregnant client who is in the first trimester to achieve the
developmental task of this stage of pregnancy, which is: - accepting the fact that she is
pregnant.
,A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete
all unfinished business as soon as possible." Which of these responses is appropriate? - "It
sounds like you are concerned with your diagnosis."
Which of these interventions should plan for a child who is receiving chelation therapy for
lead poisoning? - Keeping an accurate record of intake and output.
A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up
first? - Respiration, 30/minute and deep.
When determining the duration of a uterine contraction, a nurse should measure the
contraction from the: - beginning of one contraction to the end of that contraction.
A nurse should recognize which of these signs is a probably sign of pregnancy? - Positive
pregnancy test.
All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown?
- An 84-year-old client who has been NPO for four days.
A client diagnosed with type 1 diabetes mellitus has a
glycosylated hemoglobin A1c of 4.2%. A nurse should interpret this to mean that the client
has: - been in relatively good diabetic control.
A nurse is caring for a client with burns and in reverse isolation. Which measures should the
nurse include? - Wearing a gown, mask, and gloves when providing care to the client.
A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is
250 mg/5 mL. How many milliliters should a nurse administer? - 2.0
, A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something
that happened at 9:00 A.M. to a client who was not charted. Which of these actions should
the nurse take? - Enter the scenario after the original 2:00 P.M. charting and mark it as a
"late entry".
While giving a bath to a client, a nurse notices that the client's back appear reddened. Which
of these interpretations and additional assessments should the nurse make? - The client is
showing signs of pressure; press on the skin and observe for a return of color.
A newborn is placed under fluorescent light as part of the treatment for physiologic
jaundice. During the duration of the newborn's treatment, a nurse should: - cover the
newborn's closed eyes with patches.
When interacting with a client who is paranoid, a nurse should: - maintain a professional
attitude towards the client.
Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an
acute care unit? - Measure the blood pressure of a client who was admitted with an asthma
attack yesterday.
Which of these techniques should a nurse plan to use with a client who is delusional? - Focus
on reality-based topics.
Which of the following manifestations should a nurse recognize as suggestive of right-sided
heart failure? - Jugular vein distention and pedal edema.
Which of these statements, if made by a nursing student prior to a sterile dressing change,
is correct? - "I understand that sterile objects that are below my waist are considered
contaminated."