26. A nurse is caring for a child who is on a clear liquid diet. At lunch,
the child consumed 1⁄2 cup of juice, 3oz gelatin, 1 oz ice pop, and 20
mL ginger ale. How many mL should the nurse record as the child’s
fluid intake?
a. 260`
33.A client is prescribed half-strength tube feeding formula at 100
mL/hr. The tube feeding comes in cans of 260 mL. When mixing the
formula in the delivery system, how many mL of water should the
nurse add per can of formula? mL.
a. 260ml
33. A nurse is teaching a client who has septic shock about the
development of disseminated intravascular coagulation (DIC). Which of
the following statements should the nurse make?
a. “DIC is caused by abnormal coagulation involving fibrinogen.”
35. A nurse on the intensive care unit is caring for a client who has severe
traumatic brain injury and a cerebral perfusion pressure (CPP) of 91 mmHg.
Which of the following actions should the nurse take? She might also put
CPP 58. The answer is the same for either or.
a. Adjust client’s head of bed
36.A nurse is assessing a client who has diabetes insipidus. Which of the
following findings is a manifestation of this diagnosis?
a. Tachycardia
37.A nurse is assessing a client who has meningitis and notes the
client’s hips and knees flex when neck is flexed.
a. Brudzinski’s sign
38. A nurse is planning care for a client who has viral hepatitis. Which of the
following actions should the nurse include in the plan of care?
a. Provide a high carbohydrate diet
39. A nurse in the neuro intensive care unit is implementing a plan of care for
a conscious client recovering from a cervical cord injury. Which of the
following acute assessment findings are consistent with autonomic
dysreflexia? SATA
a. Paroxysmal Hypertension
b. Polyuria
c. Tachycardia
40. 4.
A nurse is providing
Decreased bowel discharge
soundsteaching to a client who has a new
arteriovenous
5. Poundingfistula in the right forearm. Which of the following
Headache
manifestations should the nurse include in the teaching to immediately
report to health care provider?
This study source was downloaded by 100000847097152 from CourseHero.com on 07-26-2023 14:58:1 GMT -05:00
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, a. Cold and numbness distal to the fistula site
41. A female middle adult client tells a nurse that she tested positive for a
mutant BRCA1 gene. The nurse should recognize that the client is at an
increased risk for which of the following situations?
a. Developing breast cancer
42. A nurse is caring for a client who is receiving total parenteral nutrition via
a peripherally inserted central catheter (PICC). When assessing the client,
the nurse notes swelling of the client’s arm above the PICC insertion site.
Which of the following actions should the nurse take first?
a. Measure the circumference of both upper arms
43.A nurse is admitting a client who has sustained severe burn injuries
in a grease fire. The nurse shades in a diagram indicating the burned
surface areas. Using the rule of nines, the nurse should estimate
that the client has burned what percentage of body surface area?
(Round the answer to the nearest tenth. Use a leading zero if it
applies. Do not use a trailing zero.) 18+9+4.5 =31.5%
a. 31.5%
44.A nurse is preparing a client who is scheduled for an echocardiogram
the following day. Which of the following instructions should the
nurse include about the test?
a. It requires laying quietly on one side
45.A nurse is caring for a client that just had a cardiac catheterization
via femoral artery approach. Which of the following nursing
intervention should the nurse include in the client’s plan of care?
SATA
1. Check peripheral pulses in the affected extremity
2. Keep the client’s hip and leg extended
3. Have the client remain in bed up to 6 hr
46. A nurse is instructing a client about the seven warning signs of
cancer. Which of the following signs should the nurse include as
manifestations of cancer? SATA
1. A non-healing sores
2. Change in bowel pattern
3. Change in moles
4. Nagging cough
This study source was downloaded by 100000847097152 from CourseHero.com on 07-26-2023 14:58:44 GMT -
https://www.coursehero.com/file/119576655/A-nurse-is-caring-for-a-child-who-is-on-a-clear-liquid-
the child consumed 1⁄2 cup of juice, 3oz gelatin, 1 oz ice pop, and 20
mL ginger ale. How many mL should the nurse record as the child’s
fluid intake?
a. 260`
33.A client is prescribed half-strength tube feeding formula at 100
mL/hr. The tube feeding comes in cans of 260 mL. When mixing the
formula in the delivery system, how many mL of water should the
nurse add per can of formula? mL.
a. 260ml
33. A nurse is teaching a client who has septic shock about the
development of disseminated intravascular coagulation (DIC). Which of
the following statements should the nurse make?
a. “DIC is caused by abnormal coagulation involving fibrinogen.”
35. A nurse on the intensive care unit is caring for a client who has severe
traumatic brain injury and a cerebral perfusion pressure (CPP) of 91 mmHg.
Which of the following actions should the nurse take? She might also put
CPP 58. The answer is the same for either or.
a. Adjust client’s head of bed
36.A nurse is assessing a client who has diabetes insipidus. Which of the
following findings is a manifestation of this diagnosis?
a. Tachycardia
37.A nurse is assessing a client who has meningitis and notes the
client’s hips and knees flex when neck is flexed.
a. Brudzinski’s sign
38. A nurse is planning care for a client who has viral hepatitis. Which of the
following actions should the nurse include in the plan of care?
a. Provide a high carbohydrate diet
39. A nurse in the neuro intensive care unit is implementing a plan of care for
a conscious client recovering from a cervical cord injury. Which of the
following acute assessment findings are consistent with autonomic
dysreflexia? SATA
a. Paroxysmal Hypertension
b. Polyuria
c. Tachycardia
40. 4.
A nurse is providing
Decreased bowel discharge
soundsteaching to a client who has a new
arteriovenous
5. Poundingfistula in the right forearm. Which of the following
Headache
manifestations should the nurse include in the teaching to immediately
report to health care provider?
This study source was downloaded by 100000847097152 from CourseHero.com on 07-26-2023 14:58:1 GMT -05:00
https://www.coursehero.com/file/119576655/A-nurse-is-caring-for-a-child-who-is-on-a-clear-liquid-dietdocx/
, a. Cold and numbness distal to the fistula site
41. A female middle adult client tells a nurse that she tested positive for a
mutant BRCA1 gene. The nurse should recognize that the client is at an
increased risk for which of the following situations?
a. Developing breast cancer
42. A nurse is caring for a client who is receiving total parenteral nutrition via
a peripherally inserted central catheter (PICC). When assessing the client,
the nurse notes swelling of the client’s arm above the PICC insertion site.
Which of the following actions should the nurse take first?
a. Measure the circumference of both upper arms
43.A nurse is admitting a client who has sustained severe burn injuries
in a grease fire. The nurse shades in a diagram indicating the burned
surface areas. Using the rule of nines, the nurse should estimate
that the client has burned what percentage of body surface area?
(Round the answer to the nearest tenth. Use a leading zero if it
applies. Do not use a trailing zero.) 18+9+4.5 =31.5%
a. 31.5%
44.A nurse is preparing a client who is scheduled for an echocardiogram
the following day. Which of the following instructions should the
nurse include about the test?
a. It requires laying quietly on one side
45.A nurse is caring for a client that just had a cardiac catheterization
via femoral artery approach. Which of the following nursing
intervention should the nurse include in the client’s plan of care?
SATA
1. Check peripheral pulses in the affected extremity
2. Keep the client’s hip and leg extended
3. Have the client remain in bed up to 6 hr
46. A nurse is instructing a client about the seven warning signs of
cancer. Which of the following signs should the nurse include as
manifestations of cancer? SATA
1. A non-healing sores
2. Change in bowel pattern
3. Change in moles
4. Nagging cough
This study source was downloaded by 100000847097152 from CourseHero.com on 07-26-2023 14:58:44 GMT -
https://www.coursehero.com/file/119576655/A-nurse-is-caring-for-a-child-who-is-on-a-clear-liquid-
