Graded A+
1. When caring for a group of pediatric patients, who should the nurse evaluate
first?
A client who has celiac disease and abdominal distention.
A client who has cystic fibrosis and has a paroxysmal cough.
A client who is prescribed cromolyn sodium (Crolom) and has a peak
expiratory flow rate of 79%.
A client who is prescribed digoxin (Lanoxin) and has had three
episodes of vomiting.
2. What is the priority action a nurse should take after applying a cast for a
radial head fracture?
Elevate the extremity above the heart.
Evaluate neurovascular status.
Promote adequate intake of calcium.
Apply ice intermittently for the first 24 hours.
3. Why is it appropriate for the charge nurse to assign the adolescent who is 2
days post-op following an appendectomy to the nurse from the labor and
delivery unit?
The adolescent's condition is stable and requires routine post-
operative care, which is within the scope of practice for a nurse
from any unit.
The adolescent is at high risk for complications that require intensive
monitoring.
, The adolescent has complex needs that are better suited for a
pediatric nurse.
The adolescent requires specialized care that only a labor and
delivery nurse can provide.
4. What is the significance of evaluating the client with pain and warmth in the
calf first?
The redness and swelling at the incision site suggest an infection that
needs immediate care.
The symptoms may indicate a potential deep vein thrombosis (DVT),
which is a medical emergency.
The client with a GI bleed is more critical due to low hemoglobin
levels.
The client is experiencing normal post-operative pain that does not
require immediate attention.
5. A nurse on a medical unit has received a report on four clients. Which client
should the nurse evaluate first?
client who has HF with 2+ pitting edema in lower extremities
client with DM and HbA1C of 9%
client with COPD and O2 saturation of 90%
client who has a fever of 38.4 C (101.2 F) with tenderness in the right
lower quadrant
6. In a scenario where a patient exhibits lethargy following a cerebrovascular
accident, what immediate nursing intervention should be prioritized to assess
for increased intracranial pressure (ICP)?
Administer intravenous fluids
, Position the patient in a supine position
Increase the patient's oxygen supply
Perform a neurological assessment
7. A client with cancer received platelet infusions 24 hours ago. Which of the
following assessment findings would indicate the most therapeutic effect
from the transfusions?
a WBC count of 11 000
a decrease in oozing of blood from the IV site
a hemoglobin level decrease from 8.9 to 8.7 g/dL
a temperature reading of 37.7 degrees
8. A nurse is caring for a client who has hemiplegia following a stroke. the
client's adult son is distressed over his mother's crying and condition. which
of the following responses should the nurse make?
if you just sit quietly with your mother, im sure she will calm down
your mother's crying seems to bother you more than it does her
it must be hard to see your mother so ill and upset
ill talk with your mother and see if i can comfort her
9. A nurse is caring for a child who is 24 hours postoperative from a
supratentorial craniotomy and is found to be in a prone position. What
immediate action should the nurse take?
Administer pain medication as prescribed.
Document the child's position in the medical record.
Notify the physician of the child's position.
, Reposition the child to supine with head of bed elevated to 30
degrees.
10. In a scenario where a client with diabetes is experiencing hypoglycemia,
which task should the nurse prioritize for the assistive personnel?
Bathe a client who is scheduled for physical therapy.
Perform fingersticks for glucose levels on a client who has
diabetes.
Stock procedure rooms with necessary supplies.
Distribute clean linens to patient rooms.
11. Which of the following is required when a patient is subjected to any type of
invasive procedure?
Passive consent
Informed consent
Implied consent
Active consent
12. Which of the clients requires immediate intervention?
cystic fibrosis and has a paroxysmal cough
prescribed digoxin and had had 3 episodes of vomiting
prescribed cromolyn sodium and has peak expiratory flow rate of
79%
celiac disease and abdominal distention
13. If a nurse observes a pediatric client on digoxin who has not vomited but
shows signs of confusion and lethargy, what should be the nurse's priority