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1. A nurse in an emergency department completes an assessment on an
adolescent client that has conduct disorder. The client threatened suicide to
the teacher. Which if the following statements should the nurse include in the
assessment?
a. Tell me about your siblings
b. tell me what kind of music you like
c. tell me how often you drink
d. tell me about your school schedule: C
2. A nurse is observing bonding with the client and her newborn. Which of the
following actions by the client requires the nurse to intervene?
a. holding the newborn in an enface position
b. asking the father to change the newborns diaper
c. requesting the nurse take the newborn to the nursey so she can rest
d. viewing the newborns actions to be uncooperative: d.
3. The nurse is caring for a client who is taking levothyroxine. Which of the
following findings should indicate that the medication is effective?
a. weight loss
b. decreased BP
,c. absence of seizures
d. decrease inflammation: A
4. A nurse is planning discharge teaching for cord care for the parent of a
newborn. Which instructions would you include in the teaching?
a. Contact provider if the cord turns black
b. clean the base of the cord with hydrogen peroxide daily
c. keep the cord dry until it falls off
d. the cord stump will fall off in 5 days: C
5. A nurse is assessing a client in the PACU. Which of the following findings
indicates decreased cardiac output?
a. shivering
b. oliguria
c. bradypnea
d. constricted pupils: B
6. A nurse is assisting with mass casualty triage explosion at a local factory.
Which of the following client should the nurse identify as the priority?
a. client with massive head trauma
b. client with full thickness burns
c. client with indications of hypovolemic shock
d. client with open fracture: C
,7. A nurse is receiving 4 patients. Which of the following clients should the
nurse assess first?
a. a client who has ileal conduit and mucus in the pouch
b. client AV has additional vibration palpated
c. client who has chronic kidney disease with cloudy dialysate outflow
d. a client with TURP has red tinged urine in bag: C
8. A nurse is caring for a client who just received the first dose of lisinopril.
The following is an appropriate nursing intervention?
a. place cardiac monitoring
b. monitor clients oxygen saturation
c. provide standby assist with the client from bed
d. encourage foods high in potassium: C
9. A nurse is caring for a client who is in labor and is receiving electronic
fetal monitoring. The nurse is reviewing the monitor tracing and notes early
decelerations. Which of the following should the nurse expect?
a. fetal hypoxia
b. abrupto placentae
c. post maturity
d. head compression: D
10. A nurse is caring for a client who has chronic kidney disease. The nurse
should identify which of the following laboratory values as an indication for
hemodialysis?
a. glomerular filtration rate of 14mL/min
b. BUN 16
c. serum mag 1.8
, d. serum phosphorus 4: A
11. A nurse is caring for an infant who has a prescription for continuous pulse
oximetry. The following is an appropriate action for the nurse to take?
a. place infant under radiant warmer
b. move the probe site every 3 hours
c. heat the skin one minute prior to placing the program
d. placed a sensor on the index finger: C
12. A nurse in a mental health facility receives a change of shift report on four
clients. Which of the following clients should the nurse plan to assess first?
a. Client placed in restraints to the aggressive behavior
b. a new limited client with hx of 4.5kg weight loss in the past 2 months.
c. client is receiving PRN dose
d. client that would be receiving first ECT treatment today: