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Grade A.,,
The nurse completing the admission assessment of a 3-year-old who is admitted with
bacterial meningitis and hydrocephalusWhich assessment evidence that the child is
experiencing increased intracranial pressure (ICP) - Sluggish and unequal pupillary
responses
A client with acute pancreatitis is admitted with severe , piercing abdominal pain and an
elevated serum amylase . Which additional information is the client most likely to report to
the nurse ? - Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospitalWhich information is most important for the nurse to provide the parents prior to
discharge? - Instructions about how much fluid the child should drink daily .
To auscultate for a carotid bruitthe nurse places the stethoscope at what location (Select the
correct location on the image. To change, click on a new location) -
After receiving report on an inpatient acute care unit, which client should the nurse assess
first? - The client with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity
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,A teenager presents to the emergency department with palpitations after vaping at a
partyThe client is anxious, fearful, and hyperventilatingThe anticipates the developing which
acid base imbalance? - Respiratory alkalosis
A with dyspnea is being admitted to the medical unitTo best prepare for the client's arrival,
the nurse should ensure that the client's bed is in which ? - Picture with the bed sitting
up
The nurse is taking the blood pressure measurement of a client with Parkinson's disease.
Which information in the admission assessment is relevan to the nurse's plan for taking the
blood pressure reading? (Select all that apply) - Blurred vision
Flat affect
Frequent syncope
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the
wound. Before reporting this finding to the healthcare provider the nurse should review
which of the client's laboratory values ? - Culture for sensitive organisms.
A preschool aged boy is admitted to the pediatric unit following successful resuscitation from
a near -drowning incident While providing to the child , the nurse begins with brother who
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,rescued the child from the swimming pool and initiated resuscitation The nurse notices the
older boy becomes withdrawn when asked about what happened Which action should the
nurse take ? - Ask the older brother how he felt during the incident
A male client with cirrhosis has jaundice and prunitus. He tells the nurse that he has been
soaking in hot baths at
night with no relief of his discomfort. Which action should the nurse take ? - Encourage
the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and
heart failure (HF) arrives in the Emergency Department ED) respiratory distressThe healthcare
provider prescribes furosemide IVWhich therapeutic response to furosemide should the nurse
expected in the with acute HF? - Reduced reload
Which intervention should the nurse include in the plan of care for a child with tetanus? -
Minimize the amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9is admitted to
the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the
ketoacidosis? - Had a cold and ear infection for the past two days
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, A iclient iwith ia iprescription ifor i" ido inot iresuscitate i( iDNR i) ibegins ito imanifest isigns iof
impending ideath i. iAfter inotifying ithe ifamily iof ithe iclient's istatus i, iwhat ipriority iaction ishould
i
the inurse iimplement i? i- i
i The iclient's ineed ifor ipain imedication ishould ibe idetermined.
Which iself icare imeasure iis imost iimportant ifor ithe inurse ito iinclude iin ithe iplan iof icare iof ia iclient
recently idiagnosed iwith itype i2 idiabetes imellitus i- i
i Blood iglucose imonitoring
A iclient iwho igave ibirth i48 ihours iago ihas idecided ito ibottle ifeed ithe iinfantDuring ithe
assessment, ithe inurse iobserves ithat iboth ibreasts iare iswollen, iwarm iand itender ion
i
palpationWhich iinstruction ishould ithe inurse iprovide? i- i
i Apply iice ito ithe ibreast ifor
comfort
i
The inurse iis ipreparing ia iclient iwho ihad ia ibelow-the-knee i(BKA) iamputation ifor idischarge ito
home. iWhich irecommendations ishould ithe inurse iprovide ithis iclient? i(Select iall ithat iapply.) i-
i
Inspect iskin ifor iredness
Use ia iresidual ilimb ishrinker
i
Wash ithe istump iwith isoap iand iwater
A itoddler ipresenting iwith ia ihistory iof iIntermittent iskin irashes, ihives, iabdominal ipain, iand
vomiting ithat ioccurs iafter iingesting iof imilk iproducts iarrives ito ithe iclinic iaccompanied iby ithe
i
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