RATED A+
A female client presents in the emergency department and tells the nurse that she was raped last
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night. Which question is most important for the nurse to ask?
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A. Has she taken a bath since the rape occurred?
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B. Is the place where she lives a safe place?
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C. Does she know the person who raped her?
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D. Did she report the rape to the police department? - Correct Answers A. Has she taken a bath
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since the rape occurred?
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Il` The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial
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Il` meningitis and hydrocephalus. Which assessment finding is evidence that the child is Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`
Il` experiencing increased intracranial pressure (ICP)? Il` Il` Il` Il`
A. Tachycardia and tachypnea
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B. Sluggish and unequal pupillary responses
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C. Increased head circumference and bulging fontanels
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D. Blood pressure fluctuations and syncope - Correct Answers B. Sluggish and unequal pupillary
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responses
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Il` A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated
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Il` serum amylase. Which additional information is the client most likely to report to the nurse?
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A. Abdominal pain decreases when lying supine
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B. Pain lasts an hour and leaves the abdomen tender
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C. Right upper quadrant pain refers to right scapula
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D. Drinks alcohol until intoxicated at least twice weekly. - Correct Answers A. Abdominal pain
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decreases when lying supine
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,Il` A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital.
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Il` Which information is most important for the nurse to provide the parents prior to discharge?
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A. Instructions about how much fluid the child should drink daily.
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B. Signs of addiction to opioid pain medications
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C. Information about non-pharmaceutical pain relief measures
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D. Referral for social services for the child and family - Correct Answers A. Instructions about how
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much fluid the child should drink daily
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Il` To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the
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Il` location on the image with a red dot). - Correct Answers I placed the red dot on the base of the
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Il` neck on the right side
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Il` After receiving report on an inpatient acute care unit, which client should the nurse assess first?
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A. The client with an obstruction of the large intestine who is experiencing abdominal distention
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B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel
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sounds
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C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish
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fluid
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D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity -
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Correct Answers D. The client with a bowel obstruction due to a volvulus who is experiencing
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abdominal rigidity
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Il` A teenager presents to the emergency department with palpitations after vaping at a party. The
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Il` client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which
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Il` acid base imbalance?
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A. Respiratory acidosis
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B. Metabolic alkalosis
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C. Metabolic acidosis
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D. Respiratory alkalosis - Correct Answers D. Respiratory alkalosis
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,Il` A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival,
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Il` the nurse should ensure that the client's bed is in which position?
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A. SupineIl`
B. supine; feet elevated higher than head
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C. supine; head elevated higher than feet
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D. Fowlers - Correct Answers Fowlers
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Il` The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
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Il` information in the client's admission assessment is relevant to the nurse's plan for taking the
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Il` blood pressure reading? (Select all the apply)
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A. Frequent syncope
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B. Occasional nocturia
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C. Flat affect
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D. Blurred vision
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E. Frequent drooling - Correct Answers A. Frequent syncope
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C. Flat affect
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D. Blurred vision
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Il` While caring for a client's postoperative dressing, the nurse observes purulent drainage at the
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Il` wound. Before reporting this finding to the healthcare provider, the nurse should review which of
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Il` the client's laboratory values?
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A. Serum albumin
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B. Culture for sensitive organisms
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C. Serum blood glucose level
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D. Creatinine level - Correct Answers B. Culture for sensitive organisms
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, Il` A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a
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Il` near-drowning incident. While providing care to the child, the nurse begins talking with his Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`
Il` preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`
Il` The nurse notices the older boy becomes withdrawn when asked about what happened. Which
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Il` action should the nurse take? Il` Il` Il` Il`
A. Develop a water safety teaching plan for the family
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B. Ask the older brother how he felt during the incident
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C. Tell the older brother that he seems depressed
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D. Commend the older brother for his heroic actions - Correct Answers B. Ask the older brother
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how he felt during the incident
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Il` A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking
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Il` in hot baths at night with no relief of his discomfort. Which action should the nurse take?
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A. Encourage the client to use cooler water and apply calamine lotion after soaking
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B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
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C. Suggest that the client take brief showers and apply oil-based lotion after showering
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D. Explain that the symptoms are caused by liver damage and cannot be relieved - Correct
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Answers A. Encourage the client to use cooler water and apply calamine lotion after soaking
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Il` An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and
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Il` heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The
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Il` healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`
Il` the nurse expected in the client with acute HF?
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A. Increased cardiac contractility
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B. Reduced preload
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C. Relaxed vascular tone
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D. Decreased afterload - Correct Answers B. Reduced preload
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Il` Which intervention should the nurse include in the plan of care for a child with tetanus?
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