QUESTIONS AND VERIFIED DETAILED SOLUTIONS/A+GRADE
• a nurse us caring for a client who has a recent diagnosis of terminal illness. The nurse
should identify which of the following as an indication of hopelessness?
• The client wants to talk about the diagnosis with nursing staff
• The client has a decreased energy level
• The client makes funeral arrangements
• The nurse requests a second opinion
• A nurse is preparing to collect data on a preschooler. Which of the following behaviors by
the child indicates that he is ready to cooperate? (SATA)
• Allows the nurse to touch him on the arm
• Plays with toys in the examining room
• Answers questions asked by the nurse
• Sits on his parent’s lap when the nurse enters the room
• Makes eye contact with the nurse
• A nurse on a mental health unit is planning care for a group of clients. Which of the
following clients should see the nurse first?
• A client who has bipolar disorder and is displaying flight of ideas
• A client who has ADHD and has an inability to concentrate
• A client who has schizophrenia and is having command hallucinations
• A client who has depressive disorder and is withdrawn
• A nurse is caring for a client who recently gave birth to her first child. The newborn is crying
and the client states, “I can’t seem to do anything right. What should I do?” which of the
following responses should the nurse make?
• “I’ll take him back to the nursery, so you can get some rest”
• “Babies need to cry soon after they are born to develop their lungs”
• “Let me show you how to swaddle and cuddle him, then you try”
• “If I turn him on his side, maybe he’ll go back to sleep”
• A nurse is using a glucometer to measure a client’s capillary blood glucose level. Which of
the following actions should the nurse take?
• Test the first drop of blood that forms after the puncture
• Wear sterile gloves
• Keep the finger in a dependent position
• Select the central tip of the finger
• A nurse is reviewing the home medications of a client who recently had transient ischemic
attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of
the following OTC medications interacts adversely with clopidogrel?
, • Docusate Sodium
• Ranitidine
• Vitamin D3
• Naproxen
• A nurse is collecting data from a client who has a long leg cast the was applied 2 days ago.
The client’s foot is pale with a weak pedal pulse, and the client reports foot numbness. Which
of the following actions should the nurse plan to take?
• Administer opioid pain medication
• Apply an ice pack to the affected extremity
• Check for pain with passive movement of the affected extremity
• Elevate the affected extremity with several pillows
• A nurse in a provider’s office is reinforcing teaching about cigarette smoking with a client.
Which of the following adverse Effects should the nurse include in the teaching?
• Decreased hemoglobin
• Somnolence
• Bradycardia
• Decreased blood pressure
• A nurse is contributing to the development of an in-service program for mental health
nursing staff. The nurse should include that the staff can medicate a client against his will,
without a court hearing, in which of the following situations?
• A client who has a serious mental illness
• A client who is having difficulty making decision about his treatment
• A client whom the benefits of the medication outweigh the risks
• A client who is attempting to hurt himself or others
• A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of
the following instructions should the nurse include in the teaching?
• “Monitor for muscle weakness while taking this medication.”
• “Rotate the injection sites when administering the medication.”
• “Withhold the medication if your pulse rate is above 100 bpm.”
• “Increase your intake of dietary fiber to increase absorption.”
• A charge nurse is discussing confidentiality requirement with a newly licensed nurse
when sharing a client’s medical information. Which of the following individuals should
the charge nurse identify as appropriate with whom to share client information?
• A nurse from another unit after client commits suicide
• A social worker who is assigned to an involuntary committed school-age client
• A client’s partner after the client reports intimate partner abuse
• A client’s employer who is concerned about safety due to substance abuse
, • A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of
the following findings should the nurse report to the provider?
• Hgb 13.2 g/dL
• Urine protein 3 plus
• Fasting blood glucose 72 mg/dL
• BUN 15 mg/dL
• A nurse is collecting data from a client who is 4 hr postoperative following a
hemicolectomy. Which of the following findings should the nurse report to the provider
immediately?
• Pain rating of 9 on a scale of 0 to 10
• Blood pressure 160/90mmHg
• Oxygen saturation 89%
• Abdominal dressing with a moderate amount of bright head drainage
• A nurse in a provider’s office is collecting data from a client who has a history of
hypertension during his annual physical examination. Which of the following findings should
the nurse report immediately to the provider?
• kg(4.4 lb) weight gain
• Blurred vision
• Potassium 3.6 mEq/L
• Resumption of cigarette
smoking e.
• A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of
the following actions should the nurse take first?
• Place the client on bedrest
• Obtain ABG levels
• Prepare the client for a ventilation- perfusion scan
• Elevate the head of the client’s bed
• A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the
following laboratory tests is the most accurate of blood glucose effective management?
• Urine Ketones
• Glucose Tolerance test
• Glycosylated hemoglobin
• Fasting blood glucose
• A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of
the following actions by the newly licensed nurse should the supervising nurse intervene?
• Requests a client to assist with distributing lunch trays
• Tells a client he will lose his phone privileges if he does not take his medication
• Encourages a client to participate in a recreational group therapy
• Places mechanical restraints on a client who is hitting another staff member