1. A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering
questions from the family about his
... [Show More] status. Which of the following responses should the nurse make?
A. “He is doing well, although he might be in the hospital for some time.”
B. “He has an electrical burn. He is stable, and we will update you with any changes.”
C. “He has an electrical burn, which caused coagulation of some tissues.”
D. “He does not appear to have much damage and should be fine soon.”
2. A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the
following actions should the nurse take?
A. Measure from the client’s heel to the gluteal fold.
B. Measure the length of the client’s feet.
C. Measure from the client’s heel to the popliteal space.
D. Measure the client’s ankle circumference.
3. A nurse is caring for an adolescent on an inpatient mental health unit who is undergoing detoxification for a
substance use disorder. He tells the nurse that he first began using illicit drugs when his parents wouldn't allow him
to get a tattoo. Which of the following defense mechanisms is the client demonstrating?
A. Suppression
B. Intellectualization
C. Projection
D. Dissociation
4. A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury
with increased intracranial pressure. Which of the following is an appropriate nursing action?
A. Apply restraints.
B. Administer opioids.
C. Blacken the room.
D. Reduce stimuli.
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Getting Ready for exit
5. A nurse is preparing to administer a client’s daily dose of NPH insulin at 0730. The nurse should expect this type of
insulin to peak within which of the following timeframes after administration?
A. 30 min to 3 hr
B. 1 to 5 hr
C. 4 to 14 hr
D. 2 to 6 hr
6. A nurse is collecting data from a client who has a gastric ulcer. Which of the following should the nurse identify as a
priority finding and notify the provider?
A. Weight loss of 2 lb (0.91 kg) from baseline
B. Reports being thirsty
C. Dyspepsia
D. Abdominal pain radiating to the shoulder
7. A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms
should the nurse use when documenting the client bringing her fingers together, closing the spaces between them?
A. Abduction
B. Flexion
C. Adduction
D. Extension
8. A nurse manager in a health clinic is discussing complications associated with sexually transmitted infections (STIs)
with a newly licensed nurse. Which of the following statements should be included in the discussion?
A. "Herpes simplex virus can lead to pelvic inflammatory disease."
B. "A complication of syphilis during pregnancy is low-birth-weight infants."
C. "Human papillomavirus can lead to cancer of the cervix."
D. "A complication of chlamydia in males is meningitis."
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Getting Ready for exit
9. A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications
should the nurse expect to administer? (Select all that apply.)
A. Phytonadione injection
B. Hepatitis B immunization
C. Antibiotic ophthalmic ointment
D. Lidocaine gel to the umbilical stump
E. Haemophilus influenzae type b vaccine (Hib) [Show Less]