1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications?
a. Vomiting
b. Hypertension
c. Epigastric pain
d. Contractions
2. A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
a. Stay in bed at least 1 hr if unable to fall asleep
b. Take a 1 hr nap during the day
c. Perform exercises prior to bedtime
d. Eat a light snack before bedtime
3. A nurse on a telemetry unit is caring for a client who becomes unconscious and whose
monitor displays ventricular tachycardia. Which of the following actions should the nurse
take first after determining the client does not have a palpable pulse?
a. Assess heart sounds
b. Defibrillate
c. Establish IV access
d. Administer epinephrine
4. A nurse is admitting a client who 1 week postpartum and reports excessive vaginal
bleeding. The nurse does not speak the same language as the client. The client’s partner
and 10-year-old child are accompanying her. Which of the following actions should the
nurse take to gather the client’s admission data?
a. Have the client’s child translate
b. Allow the client’s partner to translate
c. Request a female interpreter through the facility
d. Ask a nursing student who speaks the same language as the client to translate
5. A nurse is caring for a client who is febrile (High fever). To reduce the client’s fever, the
nurse applies a cooling blanket. Which of the following findings indicates the client is
having an adverse reaction to the cooling?
a. Flushing
b. Tachycardia
c. Restlessness
d. Shivering (Hypothermic)
6. A nurse is caring for a client who has deep-vein-thrombosis of the left lower extremity.
Which of the following actions should the nurse take? (Exhibit)
, a. Position the client with the affected extremity lower than the heart
b. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
c. Administer acetaminophen
d. Massage the affected extremity every 4 hr
7. A nurse is reviewing assessment data from several clients. For which of the following
clients should the nurse recommend referral to a dietitian?
a. An older adult client who has a BMI of 24(18.5-24.9)
b. A client who has a nonhealing leg ulcer (diet isn’t good)
c. An older adult client who has presbyopia (age related far-sightness)
d. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4)
8. A nurse is providing discharge teaching to a client who has a chronic kidney disease and
is receiving hemodialysis. Which of the following instructions should the nurse include in
the teaching?
a. Eat 1 g/kg of protein per day
b. Take magnesium hydroxide for indigestion
c. Drink at least 3 L of fluid daily-
d. Consume foods high in potassium- restrict
9. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of
the following places the client at risk for aspiration?
a. Sitting in a high-Fowler’s position during the feeding
b. A history of gastroesophageal reflux disease
c. Receiving a high osmolarity formula
d. A residual of 65 mL 1 hr postprandial?
10. ?A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The
nurse should tell the client that she will undergo which of the following screening tests at
16 weeks of gestation?
a. Chorionic villus sampling- as early as 8 weeks
b. Cervical cultures for chlamydia- 1st appointment.
c. Nonstress test -28 weeks
d. Maternal serum alpha-fetoprotein- 16 to 18 weeks