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1) A nurse in an emergency department completes an assessment on an
adolescent client that has conduct
disorder. The client threatened suicide to teacher at school. Which of the
following statements should the
nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
,c) Tell me how often do you drink alcohol
d) Tell me about your school schedule - ANSWER ✔✔C) tell me how
often do you drink alcohol
2) *A nurse is observing bonding to the client her newborn. Which of
following actions by the client requires
the nurse to intervene?
a) Holding the newborn in an en face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
d) Viewing the newborn's actions to be uncooperative - ANSWER
✔✔d) Viewing the newborn's actions to be uncooperative
3) A nurse is caring for client who is taking levothyroxin. Which of the
following findings should indicate that
the medication is effective?
a) Weight loss (this drug acts as T4 and will normalize the effects of
hypothyroidism)
b) Decreased blood pressure
c) Absence of seizures
,d) Decrease inflammation - ANSWER ✔✔a) Weight loss (this drug
acts as T4 and will normalize the effects of hypothyroidism)
4) A nurse is planning discharge teaching for cord care for the parent of
a newborn. Which instructions would
you include in the teaching?
a) Contact provider if the cord still turns black (it's going to turn black)
b) Clean the base of the cord with hydrogen peroxide daily (clean with
neutral pH cleanser)
c) Keep the cord dry until it falls off (cord should be kept clean and dry to
prevent infection)
d) The cord stump will fall off in five days (cord falls off in 10-14 days) -
ANSWER ✔✔c) Keep the cord dry until it falls off (cord should be
kept clean and dry to prevent infection)
5) A nurse is assessing a client in the PACU. Which of the following
findings indicates decreased cardiac output?
a) Shivering
b) Oliguria
c) Bradypnea
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, d) Constricted pupils - ANSWER ✔✔b) Oliguria
6) A nurse is assisting with mass casualty triage: explosion at a local
factory. Which of the following client
should the nurse identify as the priority?
a) A client that has massive head trauma
b) A client has full thickness burns to face and trunk
c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity - ANSWER ✔✔c)
A client with indications of hypovolemic shock
7) A nurse is a receiving report on four clients. Which of the following
clients should the nurse assess first?
a) A client who has illeal conduit and mucus in the pouch
b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged
urine in the bag - ANSWER ✔✔c) A client whose chronic kidney
disease with cloudy diasylate outflow