A 10-year-old client who has been scheduled for an appendectomy and, against medical
advice, left the hospital but now has suddenly had pain relief. ANSWER A nurse on a
pediatric unit receives change-of-shift report about four children. Which of the following
children should the nurse assess first?
Provide the client with fall precautions - ANSWER A nurse on an inpatient unit is caring
for a client who has schizophrenia and recently started taking risperidone. Which of the
following actions should the nurse take?
Increased lens opacity QUESTION A nurse is assessing a client who has some loss of
visual acuity secondary to cataracts. Which of the following physiological alterations
would the nurse expect contributes to the client's impaired vision?
Cervical laceration QUESTION ANSWER A nurse is providing postdelivery care for a
client after a vacuum-assisted delivery. The nurse should observe the client for which of
the following complications associated with vacuum-assisted delivery?
Evaluate the client's reading ability. ANSWER A nurse is revising the plan of care for a
client who is 48 hr postoperative from a laryngectomy and cannot speak. The nurse
should plan to take which of the following actions first?
Hemoglobin 14.9 g/dL - ANSWER A nurse is assessing a client who received 2 units of
packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that
the therapy has been effective?
Serum sodium 138 mEq/L - ANSWER A nurse is caring for a school-age child who has
dehydration and is receiving an oral rehydration solution. Which of the following
laboratory results indicates that the treatment regimen is effective?
Observe the environment for any hazards that might be present to the children or staff.
,QUESTION A school nurse is dispatched to a crisis in which several children were hurt
after playground equipment had fallen. What should the nurse do first when reporting to
the playground?
Continue with the provision of medical care. ANSWER An emergency department nurse
is working with a client who is unconscious and requires emergency medical
treatments. The nurse is unable to locate members of the client's family with whom to
obtain consent. Which of the following should the nurse do?
Serum liver enzyme levels ANSWER A nurse is providing care for a school-age child who
is taking valproic acid. The nurse should anticipate the provider will order which of the
following diagnostic tests?
Listing events to be done ANSWER A nurse manager is preparing to instruct a class of
new licensees on time management. Which of the following is the most crucial step of
this time management process should be included by the nurse manager?
Withhold the heparin infusion. ANSWER A nurse is providing care for a client who has a
pulmonary embolism. The client is on heparin continuous IV infusion at 1,200 units/hr
and warfarin 5 mg PO daily. The morning laboratory values for the client include aPTT of
98 seconds and INR of 1.8. What should the nurse do?
Administer the medication 15 minutes before exercising. A nurse is teaching a
school-age child with asthma who has asthma to use an albuterol metered-dose inhaler.
Which of the following is it appropriate for the nurse to include?
"My child has only a small amount of mucus after percussion therapy." - ANSWER A
home health nurse is assessing a school-age child with cystic fibrosis. The nurse should
begin a referral process for a high-frequency chest compression vest based on which of
the following statements by the parent?
Do not include fresh fruits in the client's diet. ANSWER The nurse is planning care for a
client who is undergoing chemotherapy and is neutropenic. Which of the following
interventions should the nurse include in the plan?
, Quantity of vaginal bleeding - ANSWER A nurse is providing care for a client who is in
the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of
the following findings is most important for the nurse to assess?
Hyponatremia - ANSWER A nurse is caring for a client who is in the resuscitation phase
of burn injury. Which of the following findings should the nurse expect?
"I'll have to weigh you every day." ANSWER A nurse is planning care for a client who has
newly prescribed total parenteral nutrition administered through a central line. Which of
the following information should the nurse include in the teaching?
Flight of ideas - ANSWER A nurse is evaluating a client who has bipolar disorder. Which
of the following alteration in speech is the client exhibiting?
A client whose caregiver requests adult day care services - ANSWER A home health
nurse is providing care for a group of older adult clients. The nurse should begin to
make a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of
the following clients?
A client who was abused as a child describes the abuse as if it happened to someone
else. - ANSWER A nurse at a mental health clinic is caring for four clients. The nurse
should recognize that which of the following clients is using dissociation as a defense
mechanism?
Isolation room with negative pressure. ANSWER A nurse is caring for a client diagnosed
with active pulmonary tuberculosis. Which of the following is appropriate nursing care?
"You will need to fast the night before the test." - ANSWER A nurse is providing teaching
to a client who is at 24 weeks gestation and is scheduled for a 3-hr oral glucose
tolerance test. Which of the following instructions should the nurse include in the
teaching?
"I will have my child receive annual influenza vaccination." Anorca A nurse is teaching a
parent of a school-age child with asthma. Which of the following statements by the