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, A client vomits during a continuous nasogastric tube feeding. A nurse should stop the
feeding and take which of these actions?
a. Suction the nasogastric tube.
b. Flush the tube with 30 mL of sterile water.
c. Remove the nasogastric tube.
d. Check the residual volume. - D
Which of these assessments is the priority for a client who sustained second-
degree burns of the face and neck?
a. Respiratory status.
b. Renal function.
c. Level of pain.
d. Signs of infection. - A
Which of these instructions should a nurse include in the teaching plan for a client
who had removal of a cataract in the left eye?
a. "Forcefully cough and take deep breaths every two hours to keep your airway clear."
b. "Perform the prescribed eye exercises each day to strengthen your eye muscles."
c. "Rinse your eyes with saline each morning to prevent postoperative infection."
d. "Take the prescribed stool softener to avoid increasing intraocular pressure." - d
Which of these actions best demonstrates cultural sensitivity by a nurse?
a. The nurse talks in a slow-paced speech.
b. The nurse asks clients about their beliefs and practices toward pregnancy.
c. The nurse uses charts and diagrams when teaching pregnant clients.
d. The nurse can speak several different languages. - B
Which of these manifestations should a nurse expect to observe in a 3-month-old
infant who is diagnosed with dehydration?
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, a. Hyperreflexia.
b. Tachycardia.
c. Bradypnea.
d. Agitation. - B
When assessing a client's risk of developing nosocomial infection, a nurse plans to
determine potential entry portals, which include:
a. the urinary meatus.
b. vomitus.
c. contaminated water.
d. sexual intercourse. - A
A client who is on the inpatient psychiatric unit has a history of violence. Which of
these actions should a nurse take if the client is agitated?
a. Encourage the client to verbalize feelings.
b. Lock the client in a secluded room.
c. Ask the other clients to give feedback regarding the client's behavior.
d. Ignore the client's inappropriate behavior. - A
Which of these measures should a nurse include when planning care for a school-
aged child during a sickle cell crisis episode?
a. Monitoring for signs of bleeding.
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, b. Providing pain relief.
c. Administering cool sponge baths to reduce fevers.
d. Offering a high calorie diet. - B
A client has the following order for regular insulin (Humulin R) on a sliding
scale: Blood sugar 150-180 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin
Blood sugar 201-220 mg: Give 6 units of regular
insulin Blood sugar above 220 mg: Call MD
At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a
three milliliter one. Regular insulin is available as 100 units per milliliter. How many
milliliters should the nurse administer?
a. 0.04
b. 0.4
c. 4
d. 40 - A
Which of these nursing diagnosis is the priority for a client who is one-hour
postoperative after extensive abdominal surgery?
a. Risk for impaired physical mobility.
b. Risk for deficient fluid volume.
c. Risk for ineffective airway clearance.
d. Risk for infection. - C
A nurse should recognize that which of these occupations increases a person's risk
of developing hepatitis B?
a. Sanitation worker.
b. Nursery school teacher.
c. Hemodialysis nurse.
d. Fish market sales person. - C
Which of these instructions should a nurse include in the plan of care for a 32-week
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