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A nurse is admitting a client who has antisocial C. Uses others for personal gain
personality disorder. Which of the following client
behaviors should the nurse identify as consistent with this
disorder?
A. Compulsive attention to details
B. Avoids interacting with others
C. Uses others for personal gain
D. Socially awkward in group situations
A nurse is interpreting the cardiac rhythm strip of a client
who was admitted with syncope. Which of the following
images indicates that the client has atrial fibrillation?
A client who has a diagnosis of complete placenta previa C. Prepare the client for a cesarean section
is admitted to the labor and delivery suite at 36 weeks
gestation with contractions 5 min in frequency and 1 min
in duration. Which of the following actions should the
nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
,A charge nurse on a pediatric unit is making assignments A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
for a float nurse from the medical unit. Which of the
following clients is appropriate to assign to the float
nurse?
A. A 10-year-old client who has pneumonia and is
receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is
receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical
repair of a ventricular septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge
today following placement of a Harrington rod
A nurse notices smoke coming from a client's room and A. Notify the facility operator.
discovers a fire in the wastebasket. After moving the
client to safety, which of the following is the priority
action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher.
A nurse is assessing an infant who has water intoxication. A. Generalized edema
Which of the following findings should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
A nurse is discussing the z-track administration of This technique decreases the risk of subcutaneous infiltration
hydroxyzine with a newly licensed nurse. Which of the
following statements indicates the newly licensed nurse
understands the purpose of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous
infiltration
C. This technique allows a larger amount of medication to
be injected
D. This technique increases the absorption rate of the
drug
A nurse is creating a plan of care for a client who has C. Monitor the client for 1 hr after meals
anorexia nervosa. Which of the following interventions
should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout
hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
, A nurse is planning care for a child who has increased B. Maintain the head at a midline position
intracranial pressure with a decrease in level of
consciousness. Which of the following interventions
should the nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs
10. A nurse is assessing a client who has delirium due to a A. Hallucinations
febrile illness. Which of the following findings should the
nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
A nurse is assessing a client who is receiving enteral D. Bounding pulses
feedings via a gastrostomy tube. The nurse should
identify that which of the following findings indicates fluid
overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
A nurse is caring for a client following an open B. Hyperemesis
colectomy. Which of the following findings places the
client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
A home health nurse is reviewing treatment goals with a B. HbA1c
client who has diabetes mellitus. The nurse should
evaluate which of the following laboratory tests to
determine effective long-term management of blood
glucose levels?
A. 3-hr oral glucose tolerance test
B. HbA1c
C. Fasting blood glucose test
D. Urinalysis for ketones
A nurse is caring for a client who has neutropenia due to D. Use a dedicated stethoscope
HIV. Which of the following precautions should the nurse
take while caring for this client?
A. Wear an N95 respirator
B. Insert an indwelling urinary catheter to monitor urinary
output
C. Monitor the client's vital signs every 8 hr
D. Use a dedicated stethoscope