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The nurse is planning care for the a client who has fourth degree midline laceration that occurred
during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority?
A. Administer Prescribed stool softner
B. Administer prescribed PRN sleep medications.
C. Encourage breastfeeding to promote uterine involution
D. Encourage use of prescribed analgesic perineal sprays. - CORRECT ANSWERS A.
Administer Prescribed stool softner
The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What
organ lies underneath this area.
A. Duodenum
B. Gastric Pylorus
C. Liver
D. Spleen - CORRECT ANSWERS C. Liver
A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign
is she most likely to report?
A. Decreased sexual libido
B. Amenorrhea
C. Quickening
D. Nocturia - CORRECT ANSWERS B Amenorrhea
A client's daughter phones the charge nurse to report that the night nurse did not provide good
care for her mother. What response should the nurse make?
A. Ask for a description of what happened during the night
B. Tell the daughter to talk to the unit's nurse manager
C. Reassure the daughter that the mother will get better care.
D. Explain that all the staff are doing the best they can. - CORRECT ANSWERS A. Ask for
a description of what happened during the night
A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine".
According to Erikson's theory of psychosocial development, this child's behavior is a demonstration
of which developmental stage?
A. Autonomy vs. Shame and doubt.
B. Industry vs. Inferiority
,C. intiative vs. Guilt
D. Trust vs. Mistrust - CORRECT ANSWERS A. Autonomy vs. Shame and doubt.
Which action should the nurse implement in caring for a client following an electroencephalogram
(EEG)?
A. Monitor the client's vital signs q4h
B. Assess for sensation in the client's lower extremities
C. Instruct the client to maintain bed rest for eight hours
D. Wash any paste from the client's hair and scalp - CORRECT ANSWERS D. Wash any
paste from the client's hair and scalp
The nurse is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the
coccyx. Which intervention will be most helpfull in preventing further development of the
decubitus?
A. Encourage the client to eat foods high in protein
B. Assess the client with daily range of motion exercises
C. Teach the family how to perform sterile wound care
D. Ensure the IV fluids are administered as prescribed - CORRECT ANSWERS A.
Encourage the client to eat foods high in protein
What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a
hypertonic fluid space?
A. Filtration
B. Diffusion
C. Osmosis
D. Active transport - CORRECT ANSWERS C. Osmosis
The nurse is taking blood presure of a client admitted with a possible myocardial infarction. When
taking the client's BP at the brachial artery, the nurse should place the client's arm in which
position?
A. Slightly above the level of the heart
B. At the level of the heart
C. At the level of comfort for the client
D. Below the level of the heart - CORRECT ANSWERS B. At the level of the heart
What are the final parameters that produce blood pressure? (select all that apply)
A. Heart rate
B. Stroke volume
C. Peripheral resistance
D. Neuroendocring hormones
E. Muscle tone - CORRECT ANSWERS A. Heart rate
B. Stroke volume
C. Peripheral resistance
,A client begins an antidepressant drug during the second day of hospitalization. Which assessment
is most important for the nurse to include in this client's plan of care while the client is taking the
antidepressant?
A. Appetite
B. Mood
C. Withdrawl
D. Energy level - CORRECT ANSWERS B. Mood
Based on the documentation in the medical record, which action should the nurse implement
next?
A. Give the rubella vaccine subcutaneously
B. Observe the mother breastfeeding her infant
C. Call the nursery for the infant's blodd type result
D. Administer Vicodin one tablet for pain - CORRECT ANSWERS A. Give the rubella
vaccine subcutaneously
A client is adminitted to the hosptial with a diagnosis of Pneumonia. Which intervetion should the
nurse implement to prevent complications associated with Pneumonia?
A. Enourage mobilization and ambulation
B. Encourage energy conservation with complete bed rest
C. Provide humidified oxygen per nasal cannula
D. Restrict PO and intravenous fluids - CORRECT ANSWERS A. Enourage mobilization
and ambulation
The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every
6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instrutions for
reconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction =
2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric
value only) - CORRECT ANSWERS 15
Which nursing activity is within the scope of practice for the practical nurse?
A. Complete an admission assessment in the normal newborn nursery.
B. Discontinue a central venous catheter that has become dislodged
C. Observe a client rotate the subcutaneous site for an insulin pump
D. Monitor a continous narcotic epidural for a postoperative client - CORRECT ANSWERS
C. Observe a client rotate the subcutaneous site for an insulin pump
After morning dressing changes are completed, a male client who has paraplegia contaminates his
ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the
unlicensed assistive personnel?
A. Identify the need for additional supplies to provide an extra dressing change
B. Provide perianal care and collect clean linens for the dressing change
, C. Document the diarrhea that necessitates an additional dressing change
D. Position the client for access to the decubiti sties and remove dressings - CORRECT ANSWERS
B. Provide perianal care and collect clean linens for the dressing change
The nurse is planning to evaluate the effectiveness of several drugs administered by different
routes. Arrage the routes of administration in the order from fastest to slowest rate of absorption.
Subcutaenous
Intravenous
Intramuscular
Sublingual
Oral - CORRECT ANSWERS Intravenous, sublingual, intramuscular, subcutaneous, oral.
A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house
post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. The client
begins to cry softly. How should the nurse intervene?
A. Offer to call the social worker to discuss the possiblity of abortion
B. Reassure the client that the infertility specialist can help
C. Express sorrow for the client's grief and offer to sit with her
D. Chart the vital signs and amount of vaginal bleeding - CORRECT ANSWERS C. Express
sorrow for the client's grief and offer to sit with her
A terminally ill male client and his family are requesting hospice care after discharge from the
hosptial and ask the nurse to explain what kind of care they should expect. The nurse should
indicate that hospice philosophy focuses on what aspect of health care?
A. Enhance symptom management to improve end of life quality
B. facilitates assisted suicide with the client's consent
C. Offers ways to postpone the death experience at home
D. Provide training for family members to care for the client. - CORRECT ANSWERS A.
Enhance symptom management to improve end of life quality
The nurse observes a wife shaving her husband's beard with a safety razor by holding the skin taut
and shaving in the direction of the hair growth . What action should the nurse take?
A. Advsie the wife to shave against the hair growth
B. Teach the wife to keep the skin loose to avoid cuts
C. Encourage the wife to continue shaving her husband
D. Demonstrate the correct procedure to the wife - CORRECT ANSWERS C. Encourage
the wife to continue shaving her husband
To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply)
A. Posterior tibialis artery
B. Politeal artery
C. External femoral artery
D. Dorsalis pedis artery