1. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? - ANSWER- bounding
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2. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique - ANSWER- a. This technique decreases the risk of subcutaneous infiltration
3. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? - ANSWER- a. Monitor the client for 1 hr after meals
4. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action? - ANSWER- a. Close the fire door on the unit
5. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? - ANSWER- a. Hallucinations
6. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? - ANSWER- hyperemesis
6. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? - ANSWER- A1C
7. A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? - ANSWER- a. Use a dedicated stethoscope
8. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? - ANSWER- Tell the client to avoid drinking fluids 1 hr before bedtime
8. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? - ANSWER- a. Place the newborn 45 cm from the light source
9. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? - ANSWER- social worker
10. A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication - ANSWER- decreased reflexes
11. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? - ANSWER- indigestion
12. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? - ANSWER- offer oral fluids to the client
13. A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? - ANSWER- a. A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10
14. A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? - ANSWER- avocados
1. A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? - ANSWER- a. I am thankful there are no serious complications from this type of surgery
1. A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? - ANSWER- a. Uses others for personal gain [Show Less]