1. Deficit in Cranial nerve 2: results in visual impairment and lead to falls
clear objects from the walking area
2. indicate the progression of labor and are a benign finding
-nurse should continue to monitor FHR
3. Review ABGs
4. A nurse is interviewing a client who has just lost her home due to a natural
disaster. After ensuring the client's safety, which of the following actions
should the nurse take first?
Determine the client's perception of the personal impact of the
crisis
First thing in the nursing process is assessment so assess client’s feelings and
understanding of the natural disaster and its personal impact
5. An assistive personnel (AP) and a nurse are turning a client on to her right
side. Which of the following actions by the AP requires the nurse to
intervene?
Places a pillow under the client's right arm
6. A nurse in a community center is providing an educational session to a group of
women about ovarian cancer. For which of the following manifestations should the
nurse instruct the women to contact their providers?
Abd bloating
The nurse should include the presence of abdominal bloating as an early indication of
ovarian cancer as well as other manifestations which include an increase in
abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or
urgency.
7. Hypokalemia
signs and symptoms: muscle weakness and decreased deep tendon reflexes
8. Hypocalcemia
numbness and tingling of the extremities and around the mouth
9. Car safety, d/c teaching
secure the retainer clip at the level of your baby’s armpits
The nurse should instruct the client to secure the retainer clip at the level of the
newborn's axillae. The bones of the rib cage and sternum provide protection to
underlying organs in the event of a collision. Placing the clip on the abdomen
increases the risk for injury to internal organs.
10. Nurse in ED is admitting a client who has cardiac tamponade, which assessment
finding should the nurse expect?
pulsus paradoxus
The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10
mm Hg or greater on expiration than inspiration, as an expected finding of cardiac
tamponade, along with jugular vein distention, bradycardia, and hypotension.
11. Allowable foods for a client who has a hx of uric-acid based urinary calculi formation.
Which of the following foods should the nurse recommend that the client include in
his diet?
Citrus fruits such as oranges
Avoid animal-based proteins and alcohol
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