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1. A school nurse is assessing a child who has been stung by a bee. The child's
hand is swelling and the nurse notes that the child is allergic to insect stings.
Which of the following findings should the nurse expect if the child develops
anaphylaxis? (SATA)
A) Bradycardia
B) Nausea
C) Hypertension
D) Urticaria
E) Stridor: B) Nausea
D) Urticaria
E) Stridor
2. A nurse is caring for a client who is unconscious. Which of the following
actions should the nurse take when providing oral care for the client?
A) Test for the presence of the clients gag reflex
B) Place the client in the supine position
C) Use a firm toothbrush for tooth and gum care
D) Use 2 gauze-wrapped fingers to hold the mouth open: A) Test for the pres-
ence of the clients gag reflex
3. A nurse is planning care for a client who has acute myelogenous leukemia
and a platelet count of 48,000/mm^3. Which of the follow interventions should
the nurse include?
A) Avoid IM injections
B) Assess the client for ecchymosis once per shift
C) Do not allow the client to have visitors
D) Encourage daily flossing between teeth: A) Avoid IM injection
4. A nurse is preparing to assess the function of the clients trigeminal nerve
(cranial nerve V). Which of the following items should the nurse gather for the
test?
A) Sugar
B) Coffee
C) Cotton wisps
D) Snellen chart: C) Cotton wisps
5. A nurse is caring for a client with alcohol use disorder who has undergone
detoxification. Which of the following medications should the nurse expect the
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provider to prescribe to assist the client with maintaining sobriety
A) Varenicline
B) Clonidine
C) Buprenorphine
D) Disulfiram: D) Disulfiram
6. A newly admitted client who has major depressive disorder states to the
nurse, "I'm a failure, I can't even cope with the little things anymore." Which
of the following responses should the nurse provide?
A) "What happened in your life to make you feel like such a failure?"
B) "It sounds as if you are feeling pretty overwhelmed right now"
C) "Do you feel like you don't deserve to feel good about yourself?"
D) "I know you feel like that now, but you'll feel differently when you get
better": C) "Do you feel like you don't deserve to feel good about yourself?"
7. A nurse is caring for a middle-aged adult client. The nurse should identify
which of the following statements as an indication that the client has complet-
ed Eriksons developmental task for her age group?
A) "I am comfortable with my decision to choose a lifelong partner."
B) "I think I have done a good job with my children since they are all indepen-
dent now."
C) "As I look back over my life, I can see that I have achieved most of the goals
I set for myself."
D) I love my work so much that it's difficult to think about retirement.": B) "I
think I have done a good job with my children since they are all independent now."
8. A nurse is conducting an admission interview with a client. Which of the
following pieces of assessment information should the nurse collect during
the introductory phase of the interview?"
A) Clients level of comfort and ability to participate in the interview
B) Previous illnesses and surgeries
C) Events surrounding the clients recent illness
D) Sociocultural history: A) Clients level of comfort and ability to participate in the
interview
9. A nurse is planning to assess the abdomen of a client who reports feeling
bloated for several weeks. Which of the following methods of assessment
should the nurse use first?
A) inspection
B) Auscultation
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C) Percussion
D)Palpation: A) Inspection
10. A nurse is performing a comprehensive physical assessment of a client.
The nurse should use inspection to assess which of the following?
A) Liver size
B) Pedal edema
C) Skin texture
D) Gait: D) Gait
11. A nurse is caring for a client who is immobile. The nurse should recognize
that immobility places the client at risk of which of the following health
alterations?
A) Increased intestinal motility
B) Respiratory alkalosis
C) Decreased cardiac output
D) Hypocalcemia: C) Decreased cardiac output
12. A nurse is preparing to perform mouth care for an unresponsive client.
Which of the following actions should the nurse plan to take?
A) Place the client supine
B) Keep both side rails up
C) Raise the level of the bed
D) Inspect the clients mouth using a finger sweep: C)Raise the level of the bed
13. A nurse is preparing to administer an afternoon dose of ampicillin to a
client. The client appears upset and refuses to take the medication before
throwing the pill on the floor. Which of the following entries should the nurse
enter into the clients medical record?
A) the client refuses to take medication today
B) The client states, "I will not take this pill."
C) The client seemed angry and hostile
D) The client threw the medication on the floor: D) The client threw the medica-
tion on the floor
14. A nurse is a rehabilitation facility is observing an assistive personal (AP)
help a client transfer from a bed to a wheelchair. Which of the following actions
indicates to the nurse that the AP understands how to perform this task
A) Locking the brakes on the bed and the wheelchair before moving the client
B) Lowering the footplates of the wheelchair before the transfer
C) Placing the wheelchair perpendicular to the bed
D) Placing the wheelchair on the clients weaker side prior to the transfer: A)
Locking the brakes on the bed and the wheelchair before moving the client