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1. A nurse is assisting with the care ANS: Assure the client that a family
of a client who has a terminal ill- member will stay with the body after
ness. The client practices Orthodox death
Judaism. Which of the following ac-
tions should the nurse take? RAT: The nurse should assure the
client that a family member will re-
main with the body until burial
2. A nurse is reviewing a client's med- ANS: Obtain a set of the client's vital
ication record and notices that a signs
double dose of oral digoxin was ad-
ministered 1 hr ago. Which of the fol- RAT: The first action the nurse
lowing actions should the nurse take should take when using the nurs-
first? ing process is to collect data from
the client. Digoxin can cause brady-
cardia. By obtaining the client's vi-
tal signs, the nurse can identify the
need for intervention
3. A nurse is instructing an assistive ANS: Contact
personnel (AP) about caring for a
client who has hepatitis A and is in- RAT: Hepatitis A is spread by the fe-
continent of stool. Which of the fol- cal-oral route. Standard precautions
lowing infection control precautions are usually sufficient to prevent the
should the nurse instruct the AP to spread of infection. However, if the
use? client who has hepatitis A is also in-
continent of stool, then contact pre-
cautions are indicated
4. A nurse is assisting with the transfer ANS: Admission sheet
of a client to a long-term care facil-
ity. The nurse should review which RAT: The nurse will find client data,
of the following sections of the elec- such as date of birth, occupation,
tronic health record to locate infor- and the client's source of health in-
mation about the client's personal surance, on the client's admission
health insurance? sheet
5. A nurse is inspecting the skin of ANS: Generalized petechiae
a newborn. Which of the following
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findings should the nurse report to RAT: Petechiae are an expected
the provider? finding over the presenting part of
the newborn, such as on the fore-
head in a brow presentation, and
also anywhere on the head of the
newborns who has a nuchal cord,
which is an umbilical cord around the
neck. However, petechiae all over
the newborn's body can indicate
infection or a decreased platelet
count and should be reported to the
provider
6. A nurse in a provider's office is ob- ANS: "Do you know if you're allergic
taining the health history from a to iodine?"
client who is scheduled to undergo
a cardiac catheterization in 2 days. RAT: The greatest risk to the client
Which of the following questions is is an allergic reaction to the contrast
the priority for the nurse to ask? agent, which contains iodine. There-
fore, the priority question is to iden-
tify the client's allergies
7. A nurse is reviewing the medical ANS: INR 5.0
record of a client who is receiving
warfarin and has atrial fibrillation. RAT: The international normalized
Which of the following laboratory ratio (INR) is a measurement of the
values should the nurse report to the body's blood clotting ability. A client
provider? receiving warfarin to prevent clot for-
mation related to atrial fibrillation
should have an INR of 2.0 to 3.0.
An INR of 5.0 or greater indicates
that the client is at risk for bleed-
ing. Therefore, the nurse should no-
tify the provider about this laboratory
value
8. A nurse is evaluating the safe use ANS: Grasps the plug of a device in
of electrical equipment by a new- the client's room to pull it straight out
ly hired assistive personnel (AP). from the wall
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Which of the following actions by the
AP demonstrates an understanding RAT: The nurse should recognize
of the proper use of electrical equip- that by grasping the plug, rather than
ment? the cord, the AP is demonstrating an
understanding of proper equipment
use and preventing risk of injury from
electronic equipment.
9. A nurse is reinforcing discharge ANS: "I will soak my child's tooth-
teaching with the parents of a brush in warm water to soften it be-
school-age child who has severe he- fore my child uses it."
mophilia A. Which of the following
statements by the parents indicates RAT: The nurse should instruct
an understanding of the teaching? the parents to soften their child's
toothbrush in warm water before
they use it or allow them to use
a sponge-tipped disposable tooth-
brush. These actions will minimize
trauma to the gums and prevent
bleeding of the oral cavity
10. A nurse is assisting with the de- ANS: A client hits another client be-
velopment of an in-service for new- cause they thought the other client
ly licensed nurses about seclusion. was talking about them
In which of the following situations
should the nurse identify the need RAT: The nurse should request a
to request a prescription for seclu- prescription for seclusion for a client
sion? who hits another client to protect the
client and others from physical injury
11. A nurse is collecting data from a RAT: The client who has chronic
client who has chronic hepatitis. hepatitis tenderness in the upper
In which of the following locations right quadrant, which is where the
should the nurse expect the client nurse should palpate. This is the
to point to indicate hepatic tender- area where the liver is located
ness?
12. A nurse in a provider's office is re- ANS: Coronary artery disease
viewing the medical record of a client
who requests a prescription for an RAT: Coronary artery disease is a
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oral contraceptive. Which of the fol- contraindication to oral contracep-
lowing findings should the nurse tive use because it increases the
identify as a contraindication for oral client's risk for myocardial infarction.
contraceptive use? Other contraindications for receiving
oral contraceptives include gallblad-
der disease, breast cancer, and hy-
pertension
13. A nurse is assisting with the care of a ANS: 250 mL of sanguineous
school-age child immediately follow- drainage over the last 3 hr
ing surgery. The child weights 21.8
kg (48 lb) and has a chest tube ap- RAT: The nurse should recognize
plied to suction. Which of the follow- that if more than 3 mL/kg/her of san-
ing findings should the nurse report guineous drainage occurs for more
to the provider? than 3 consecutive hours following
surgery, it can indicate active hem-
orrhaging. Therefore, 250 mL of san-
guineous drainage from the child's
chest tube is excessive and the
nurse should report this finding to
the provider immediately
14. A nurse is collecting data from a ANS: Polyuria
client who is at 30 weeks of gestation
and has gestational diabetes. Which RAT: The nurse should identify poly-
of the following findings should the puria as an expected finding of hy-
nurse report to the provider as an perglycemia and report this finding
indication of hyperglycemia? to the provider
15. A nurse is discussing home safe- ANS: "I will dispose of my needles in
ty with a group of clients who have a plastic laundry detergent contain-
type 1 diabetes mellitus. Which of the er."
following client statements indicates
an understanding of the teaching? RAT: The nurse should instruct the
client to dispose of needles in a
puncture-proof container, such as a
plastic laundry detergent container.
16. A nurse is caring for a client who has ANS: Encourage the client to remi-
Alzheimer's disease. Which of the nisce about the past