1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take?
A. Tell the
... [Show More] child they will feel discomfort during the catheter insertion.
B. Use a mummy restraint to hold the child during the catheter insertion.
C. Require the parents to leave the room during the procedure. - Tell the child they will feel discomfort during the catheter insertion.
2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels.
D. Swishing sound upon auscultation. - Absence of a bruit.
3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching?
A. "I will soak in the tub rather and showering"
B. "I will wear loose clothing around my ICD"
C. "I will stop using my microwave oven at home because of my ICD"
D. "I can hold my cellphone on the same side of my body as the ICD" - "I will wear loose clothing around my ICD"
4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
A. "Describe your feelings to me about being pregnant"
B. "You should discuss your feelings about being pregnant with your provider"
C. "Have you discussed these feelings with your partner?
D. "When did you start having these feelings?" - "Describe your feelings to me about being pregnant"
5. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per day.
B. Increase the amount of refined grains in the client's diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. - Administer a rectal suppository 30 minutes prior to scheduled defecation times.
6. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions. D. Assist the client to a supine position. - Place the client in a warm shower.
7. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. to which of the following types of injuries should the nurse assign the highest priority?
A. below the knee amputation
B. fractured tibia
C. 95% full thickness body burn
D. 10 cm laceration the forearm - below the knee amputation
8. A nurse manager is updating protocols for the use of belt restraints. which of the following guidelines should the nurse include?
A. remove the clients restraints every 4 hours
B. document the clients condition every 15 min
C. attach the restraint to the bed side rails
D. request a PRN restraint pre - document the clients condition every 15 min
9. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader?
A. Acts as an advocate for the nursing unit.
B. Priorities staff request over client needs.
C. Provides routine client care and documentation. - Acts as an advocate for the nursing unit.
10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care.
A. Serum sodium 144 mEq/L)
B. Hba1c 10 %
C. Random serum glucose 190 mg/dl. - Hba1c 10 %
11. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment
A. A chest x-ray reveals increased density in all fields.
B. The client reports feeling less anxious.
C. Diminished breath sounds are auscultated bilaterally
D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. - The client reports feeling less anxious.
12. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next.
A. Monitor the client's IV site for thrombophlebitis.
B. Administer flumazenil to the client.
C. Evaluate the client for further suicidal behavior.
D. Initiate seizure precautions for the client. - Administer flumazenil to the client.
13. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect?
A. Loose stools
B. Jitteriness
C. Hypertonia
D. Abdominal distention - Jitteriness
14. A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider?
A. Hgb 12.5 g/dl
B. Platelets 250,000/mm3
C. Hct 40%
D. WBC 14,000/mm3 - WBC 14,000/mm3
15. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?
A. Turn the client on their side.
B. Administer an analgesic.
C. Administer antiemetic
D. Monitor the client's vital signs. - Turn the client on their side. [Show Less]