And Answers Verified 100% Correct
The nurse is caring for a child with an acyanotic heart defect. Which of the following would
be an expected fi nding. Select all that apply.
(a)poor suck refl ex
(b)tachycardia
(c)increased respiratory rate
(d)bradycardia
(e)fainting spells
(f)delayed growth and development
nurse is teaching a new mother about immunizations. Which of the following
should the nurse include in the teaching?
(a) ―Your baby should wait six months to receive any immunizations
since the baby was born preterm.‖
(b) ―Your baby will receive the fi rst hepatitis B vaccine after one year of
age.‖
(c) ―Acellular Pertussis vaccine has less side effects than whole-cell
pertussis vaccine.‖
(d) The Haemophilus Infl uenza Type b (HIB) is given annually to protect
against the fl u.‖
The mother of an infant tells the nurse that the baby has not been tolerating feedings
lately and she noticed an olive-shaped mass in the infant‘s abdomen. The nurse
recognizes that this could be an expected fi nding if the infant has (a) intussusception
(b) Hirschsprung‘s disease
(c) umbilical hernia (d) pyloric stenosis
. The nurse is teaching a group of parents about the expected growth and development
of three-year-old children. The nurse should include that a three-year-oldshould
(a) discriminate between fantasy and reality
(b) ride a tricycle independently
(c) have a vocabulary of 7,000 words
(d) play in a group of two or three with one being the leader
, The nurse and the nursing assistant are caring for a group of clients. Which of
the following client care activities should the nurse assign to the nursing
assistant? Select all that apply.
(a) reinforcing the dressing of a client who has a decubitus ulcer
(b) monitoring the vital signs of a client who had a myocardial infarction 12 hours
ago and is being trANSferred from the coronary care unit
(c) administering a prescribed Fleet‘s enema to a client who will undergo a
colonoscopy in two hours
(d) placing a client who had an above the knee amputation 24 hours ago in a prone
position
(e) assisting a client who had a colon resection 36 hours ago to ambulate
(f) showing a client who had a vaginal hysterectomy 36 hours ago how to perform
perineal care
The nurse is caring for a client with Acquired immunodefi ciency syndrome (AIDS)
who was started on Zidovidine (AZT). It would be important for the nurse toassess
(a) blood ammonia serum
(b) serum potassium
(c) complete blood count (CBC)
(d) serum uric acid
The nurse is performing an abdominal assessment. Indicate the correct sequence the
nurse should use to perform this assessment.
(a) percussion
(b) palpation
(c) auscultation
(d) inspection ANSwer
The nurse has become aware of the following client situations. The nurse should fi rst
assess the client who*
(a) had received a unit of packed red blood cells four hours ago and is requesting
a bedpan
(b) had an abdominal hysterectomy yesterday and is reporting calf pain
(c) has history of multiple sclerosis and is reporting diplopia (d) had a
tonsillectomy three hours ago and is reporting a sore throat
,The nurse is caring for a client who has been prescribed 1,000 ml of Ringer‘s Lactate to infuse over
8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute
should the nurse set the intravenous controller to administer?
ANSwer
The primary health care provider has prescribed an oral solution of Potassium
Chloride (KCL) 20 mEq PO, QD. The drug available is Potassium Chloride 10
mEq/15ml. How many ml should the nurse administer?
ANSwer
primary health care provider has prescribed Heparin 5000 units SC. The drug
available is heparin sodium 7500units/ml. Choose all of the correct ANSwers for
nursing considerations for the administration of heparin sodium.
(a)administer the heparin in the abdomen
(b)administer 0.5ml of heparin sodium
(c)aspirate after inserting the needle
(d)use a 1 inch 21 gauge needle
(e)refrain from massaging the site after administer heparin
(f)remember that protamine sulfate is the antidote for heparin
The nurse has attended a staff development conference on cultural considerations for
clients receiving hospice care. Which of the following statements if made by the
nurse would require follow-up?
(a) The family of a client of the Buddhist faith may ask for a priest to be present at the
time of death
(b) The family of a client of the Jewish faith may request to have mirrors covered after
the death of the client
(c) The family of a client of the Muslim faith may request that the body of the client be
turned to face the East at the time of the client‘s death
(d) The family of a client of the Hindu faith may request that the client body be bathed
after the client‘s death
The nurse is caring for a client with bipolar disorder who has Lithium (Lithotabs)
prescribed. The nurse should suggest that the client have which of the following
snacks?
(a) A fresh fruit cup
(b) Coffee and oatmeal cookies
, (c) Tuna fi sh salad on saltine crackers
(d) Raw vegetables
The nurse has provided discharge instructions for a client who has been prescribed Digoxin
(Lanoxin). It would require follow up by the nurse if the client says
(a) ―I will consult my primary health care provider before taking medications that
contain aspirin.‖
(b) ―I will not take any antacids within two hours of taking the digoxin.‖
(c) ―I will avoid fruits such as avocados, grapefruit and cantaloupe.‖
(d) ―I will remember that any visual disturbance can be a sign of digitalis toxicity.‖
The nurse is caring for a client who has bumetanide (Bumex) prescribed. The
nurse should suggest that the client include which of the following foods in the
diet? (a) Apricots
(b) Organ meats
(c) Sardines (d) Apples
The nurse is providing teaching for a client with ulcerative colitis. Select all of
the following that the nurse should include in the teaching
(e) steatorrhea commonly occurs or excessive secretion of fecal lipids is
common
(f) ulcerative colitis occurs most frequently in Jewish males 30-50 years of
age
(g) a diet high in residue and low in complex carbohydrates is helpful in
controlling symptoms
(h) Corticosteroids may be prescribed during an exacerbation
(i) metronidazole (Flagyl) and ciprofl oxacin (Cipro) are antibiotics
commonly used during acute exacerbations
(j) eating small frequent meals and lying down after eating promotes
absorption of nutrients
The nurse is precepting a newly-hired nurse who is caring for a client receiving
a prescribed continuous nasogastric feeding. The nurse should intervene
immediately if the newly-hired nurse
(k) instills 30cc of normal saline into the feeding tube while auscultating
over the stomach for bowel sounds
(l) checks the pH of the 60ml gastric aspirate removed from the feeding
tube