1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child? - Make certain
... [Show More] the child is maintained
in correct body alignment
2. The nurse is assessing a healthy child at the 2 year check up. Which of the following
should the nurse report immediately to the health care provider? - Height and weight
percentiles vary widely
3. . The parents of a 2 year-old child report that he has been holding his breath
whenever he has temper tantrums. What is the best action by the nurse? - advise the
parents to ignore breath holding because breathing will begin as a reflex
4. The nurse is assessing a client in the emergency room. Which statement suggests
that the problem is acute angina? - My pain is deep in my chest behind my sternum
5. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment
does the nurse perform as a priority before administering the medication? - checking the
clients blood pressure
6. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client indicates
a need for further instruction? - "I need to drink citrate of magnesia the night before the
test and give myself a Fleet enema on the morning of the test."
7. 2-A nurse on the evening shift checks a physician's prescriptions and notes that the
dose of a prescribed medication is higher than the normal dose. The nurse calls the
physician's answering service and is told that the physician is off for the night and will be
available in the morning. The nurse should: - Ask the answering service to contact the
on-call physician
8. An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit.
The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the
monitor, checks the client's carotid pulse, and determines that the PVCs are not
resulting in perfusion. The appropriate action by the nurse is: - Ask the ED physician to
check the client
9. NPO status is imposed 8 hours before the procedure on a client scheduled to
undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure,
the nurse checks the client's record and notes that the client routinely takes an oral
antihypertensive medication each morning. The nurse should: - Administer the
antihypertensive with a small sip of water
10. A client who recently underwent coronary artery bypass graft surgery comes to the
physician's office for a follow-up visit. On assessment, the client tells the nurse that he is
feeling depressed. Which response by the nurse is therapeutic? - " Tell me more about
what you're feeling"
11. A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid.
The nurse notes
that the fluid is yellow and has a strong odor. Which of the following actions should be
the nurse's
priority? - contacting the physician
12. A nurse has assisted a physician in inserting a central venous access device into a
client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition
(PN). After insertion of the catheter, the nurse immediately plans to: - Call the
radiography department to obtain a chest x-ray
13. The nurse is has just admitted a client with severe depression. From which focus
should the nurse identify a priority nursing diagnosis? - Safety
14. While explaining an illness to a 10 year-old, what should the nurse keep in mind
about the cognitive development at this age? - They are able to think logically in
organizing facts
15. A home health nurse is at the home of a client with diabetes and arthritis. The client
has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the
client to - An occupational therapist from the community center
16. A priority goal of involuntary hospitalization of the severely mentally ill client is -
Protection from harm to self or others
17. The nurse is caring for a client with a long leg cast. During discharge teaching about
appropriate exercises for the affected extremity, the nurse should recommend -
isometric
18. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with
Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to
immediately report - Loss of consciousness
19. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the
client for this test, the nurse would - Administer a laxative to the client the evening
before the examination
20. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation
indicates that the membranes were ruptured for 36 hours prior to delivery. What is the
priority nursing diagnoses at this time? - Risk for infection [Show Less]