Guide
1. A client who has a diagnosis of complete placenta previa 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
…Ans>> Prepare the client for a Cesarean section
2. A nurse enters a client's room and finds the client lying on the floor in a
puddle of water. Which of the following statements should the nurse document
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Guide
in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed
down
B. Client's roommate thinks the client is confused and fell when getting out of
bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
…Ans>> Client found lying on the floor near the bedside table
3. A charge nurse on a pediatric unit is making assignments 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 Herrington rod
…Ans>> A 10-year-old client who has pneumonia and is receiving respiratory
treatments
4. A nurse is preparing to administer vancomycin to a client who has an
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infected wound. The nurse should plan to monitor for which of the
following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
…Ans>> Ototoxicity
5. Anurse is assessing an infant who haswater intoxication.Which of the
following findings should the nurse expect?
A. Generalized edema
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Guide
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
…Ans>> Thready pulse
6. A home health nurse is conducting an initial home visit for a client who
has terminal breast cancer.The client has two school-age children and a
limited support system. Which of the following is the priority nursing
action?
A. Inform the client of available community resources
B. Assist the client in finding child care options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
…Ans>> Inform the client of available community resources
7. A nurse in an emergency department is assessing a client who has a nasal
fracture. Which of the following findings should cause the nurse to suspect a
skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry