Hudson County Community College

1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? 2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? 3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? 4. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhe...

1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? 2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? 3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? 4. The nurse is reviewing a depressed client's history from an earlier admission. Documentation o...

31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung." The correct answer is B: "The tube will remove excess air from your chest." 32. The nurse is rev...

14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness The correct answer is A: Can predispose to dysrhythmias 15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the ...

41. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale? A) "Nursing will help contract the uterus and reduce your risk of bleeding." B) "Breastfeeding twins will take too much energy after the hemorrhage." C) "Th...

19. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? A) Take the client's vital signs B) Place the client in a sitting position with legs dangling C) Contact the health care provider D) Administer the PRN anti anxiety agent The correct answer is B: Place the client in a sitting pos...

1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? 2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? 3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? 4. The nurse is reviewing a depressed client's history from an earlier admission. Documentation o...

1. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age? 2. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present 3. The nurse admits an elderly Mexican-American migrant worker after an accident that occurred...

1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? 2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? 3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eye...

1. A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? 2. The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning? 3. The nurse is planning care for an 18 month-old child. Which action should be included in the child's care? ...