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A nurse is caring for a new born following a circumcision. Which of the following
manifestations indicates the newborn is experiencing pain?
A. Lip smacking
B. Diaphoresis
C. Hypoglycemia
D. Transient strabismus ---------CORRECT ANSWER-----------------A. Lip smacking
A nurse is caring for a client who is using a non-rebreather mask for oxygen
delivery. The nurse should identify which of the following as an indication that the
equipment is functioning properly?
a) Air is heard escaping from around the mask
b) The flow control meter dial is at the correct setting
c) The attached reservoir bag is inflated
d) The exhalation ports are covered during inspiration and expiration ---------
CORRECT ANSWER-----------------c) The attached reservoir bag is inflated
A nurse is caring for a client who had a transurethral resection of the prostate and
now is receiving continuous bladder irrigation. Which of the following actions
should the nurse take? (Select all that apply)
A. Document urine color.
,B. Monitor the client for reports of bladder spasms.
C. Check the drainage tubing for obstructions.
D. Maintain the client in a left side-lying position.
E. Use clean technique for intermittent irrigation. ---------CORRECT ANSWER---------
--------A. Document urine color
B. Monitor the client for reports of bladder spasms.
.C. Check the drainage tubing for obstructions.
A nurse in an urgent care clinic is collecting data from a client who reports having
diarrhea for the past 3 days. Which of the following findings indicates
hypokalemia?
A. Pitting edema
B. Diplopia
C. Muscle weakness
D. Hyperactive bowel sounds. ---------CORRECT ANSWER-----------------C. Muscle
weakness
A nurse is reinforcing teaching about home safety with the parent of an 8-month-
old infant. Which of the following statements by the parent indicates an
understanding of the teaching?
A. "I will position the crib in front of the window."
B. "I will hang some toys across the crib rails."
C. "I will keep the door to the bathroom closed."
,D. "I will set my hot water heater at 140 degrees Fahrenheit." ---------CORRECT
ANSWER-----------------C. "I will keep the door to the bathroom closed."
A nurse is admitting a client who has active tuberculosis. Which of the following
nursing interventions is appropriate?
a) Place the client in a room that is ventilated to the outside
b) Wear a gown when delivering the client's food tray
c) Prohibit visitors while the client's infection is active
d) Administer a tuberculin skin test prior to discharge ---------CORRECT ANSWER---
--------------a) Place the client in a room that is ventilated to the outside
A nurse is collecting data from a client who is 24 hr postoperative following a total
knee arthroplasty. Which of the following operative leg should the nurse identify
as a manifestation of a deep-vein thrombosis?
A. Increase in calf size
B. Capillary refill of 2 seconds.
C. Palpable cord like vein
D. Extremity feels cool to the touch. ---------CORRECT ANSWER-----------------A.
Increase in calf size
A nurse is reviewing the medical record of a client who is requesting an oral
contraceptive. Which of the following findings should the nurse identify as a
contraindication to the use of oral contraceptives?
a) History of renal calculi
, b) Migraines with aura
c) BMI of 26
d) History of cholecystectomy family ---------CORRECT ANSWER-----------------b)
Migraines with aura
A nurse is reinforcing teaching with a client who is about to undergo a
thoracentesis. Which of the following statements by the client is understanding of
the information?
A. "I will have general anesthesia during the procedure."
B. "I will lie flat for 6 hours following the procedure."
C. "I will have a chest x-ray following the procedure."
D. "I will breathe deeply through my nose during the procedure." ---------CORRECT
ANSWER-----------------C. "I will have a chest x-ray following the procedure."
A nurse is caring for an infant who is drinking a cow's milk formula and has bloody
stools. Which of the following record(?) nurse make to the infant's guardian?
A. Switch to a soy-based formula
B. Switch to a goat's milk formula
C. Switch to an unpasteurized milk formula.
D. Switch to a condensed milk formula ---------CORRECT ANSWER-----------------A.
Switch to a soy-based formula