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1. A nurse, an emergency department complete an assessment on an adoles-
cent client that has conduct disorder. The client threaten suicide to a teacher
at school which of the following statements should the nurse include in the
assessment.: Tell me how often do you drink alcohol?
2. A nurse is observing bonding to the client, her newborn, which of the follow-
ing actions by the client requires the nurse to intervene: Viewing the newborn's actions to
be uncooperative
3. A nurse is caring for a client who is taking levothyroxine, which of the follow-
ing �nding should indicate that the medication was e ective: Weight loss
4. A nurse is planning, discharge teaching for cord care for a parent of a new-
born which instructions would you include in the teaching: Keep the cord dry until it falls
o� (cord should be kept clean and dry to prevent infection)
5. A nurse is assessing a client in PACU, which of the following �ndings indicates
decreased cardiac output: oliguria
6. A nurse is assisting with mass, casualty triage explosion at a local factory
which of the following client. Should the nurse identify as a priority.: A client with
indications of hypovolemic shock
7. A nurse is receiving report on for clients which of the following client should
the nurse assess �rst: A client who is chronic kidney disease with cloudy, diasylate out ow
8. A nurse is caring for a client just received the �rst dose of lisinopril. The
following is appropriate nursing intervention.: Provide standby assist with the client from bed
9. A nurse is caring for a client who is in labor, and is receiving electronics
fetal monitoring. The nurse is reviewing the monitor tracing in notes early
decelerations, which of the following should the nurse expect: Head compression
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 of
hemodialysis.: Glomerular ltration rate of 14 ML/minute
11. A nurse is caring for an infant who has prescription for continuous pulse
oximetry. The following is an appropriate action for the nurse to take.: Heat the
skin one minute prior to placing the program
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12. A nurse in a mental health facility receives a change of shift report on four
clients which of the following client. Should the nurse plan to assess �rst.: Client
placed in restraints to the aggressive behavior
13. A nurse working at the clinic is teaching a group of clients who are pregnant
on the use of nonpharmacological pain management, which of the following
statement by the nurse is an appropriate description of the use of hypnosis
during labor: Hypnosis promotes increase control of her pain perception during contractions
14. A nurse in a County Jail health clinic is leading group therapy session. A client
who was incarcerated for theft is addressing the group. Which of the following
is an example of reaction formation?: I think that people just you're just lazy and should earn money
honestly
15. A nurse is obtaining a medical history of a client who has a new prescription
for Isosorbide monotitrate which of the following should the nurse identify as
a contraindication to medication: glaucoma
16. 16: No questions
17. The nurse is caring for a client recovering from an acute myocardial infrac-
tion, which of the following intervention should the nurse include in the point
of care: Obtain a cardiac rehabilitation consult
18. A nurse is caring for a client who has breast cancer and has been covering
receiving chemotherapy, which of the following laboratory value should nurse
report to the provider: WBC 3,000/mm3
19. Home health nurse is carefully planned for Alzheimer's disease to the follow-
ing action. Should the nurse include in the plan of care: Place a daily calendar in the kitchen
20. A nurse is performing change of shift assessments on four clients which of
the following �ndings. Should the nurse report to the provider �rst.: Client who has
gastroenteritis and his lethargic and confused
21. A nurse is caring for a client who is in the second trimester of pregnancy and
ask how to treat constipation which of the following statements by the nurse
is appropriate: Drink hot water with lemon juice each morning when you wake up
22. 22: No question
23. A nurse is caring for a client who is preparing his advance directives, which of
the following statements by the client indicates an understanding of advance
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directives SATA: I have the right to refuse treatment
My health care proxy can make medical decisions for me
24. A nurse is caring for a client who is 32 weeks gestation and has a history of
cardiac disease which of the following positions to the nurse place the client to
best promote optimal, cardiac output: Left lateral
25. A nurse is caring for a group of clients which of the following client. Should
the nurse assigned to an AP.: Client who had a cerebral vascular accident two days ago, and needs help
toileting
26. A nurse is providing discharge, teaching to a client who has schizophrenia,
isn't starting therapy with clozapine which of the following is the highest
priority for the client to report to the provider: Fever
27. A nurse observes an AP providing care to a child, who is in a skeletal traction,
which of the following action requires intervention: Placing weights as a child's bed
28. A nurse is planning to delegate twin a piece of fasting blood glucose testing
for a client who has diabetes which of the following action should the nurse
take: Determine if the AP is quali ed to perform the test
29. A nurse is assessing a client brought to the hospital psychiatric emergency
service by law-enforcement o cer. The client has just organized incoherent
speech with loose associations and religious contact. You should recognize the
signs and symptoms as being consistent with which of the following.: Schizophrenia
30. A nurse is caring for a child who has infectious mononucleosis which of the
following �ndings are associated with this diagnosis SATA: Splenomegaly
Malaise
Sore throat
31. A nurse is performing dressing change for a client with a sacral wound using
negative pressure wound therapy which of the following action should the
nurse take �rst: Determine pain level
32. A nurse is caring for a client recovery from a bowel surgery has a nasogastric
tube connected to load intermittent section which of the following assessment