1. 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
... [Show More] 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 rectalsuppository 30 minutes priorto scheduled
defecation times .
2. A nurse in a pediatric unit is preparing to insert an IV catheterfor 7-year-old. Which of the
following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parentsto leave the room during the procedure.
3. A nurse is caring for a client who has an 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.
4. A nurse is providing discharge teaching for a client who has a new implantable cardioverter
defibrillator (ICD). 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”
5. 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 responsesshould the nurse
make?
A. “Describe yourfeelingsto me about being pregnant”
B. “You should discuss yourfeelings about being pregnant with your
provider”
C. “Have you discussed these feelings with your partner?”
D. “When did you start having these feelings?”
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.
7. a nurse in an emergency department is performing triage for multiple clientsfollowing 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. 10cm (4in) laceration to the forearm
8. A nurse is planning for a client who practices Orthodox Judaism. The clienttellsthe nurse
that (Unable to read) Passover holiday. Which of the following action should the nurse
include in the plan of care?
A. Provide chicken with cream sauce.
B. Avoid serving fish with fins and scales.
C. Provide unleavened bread.
D. Avoid serving foods containing lamb.
9. A nurse is caring for a client who has a pulmonary embolism. How should the nurse should
identify the effectiveness of the treatment?
A. A chest x-ray revealsincreased density in all Nelds.
B. The client reportsfeeling 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.
10. A nurse in an emergency department is assessing a client who reports ingesting thirty
diazepam tablets and now has a respiratory rate of 10/min. After securing the client’s
airway and initiating an IV, which of the following actionsshould the nurse do next.
A. Monitorthe client’sIV site forthrombophlebitis.
B. Administer Flumazenil to the client.
C. Evaluate the client forfurthersuicidal behavior.
D. Initiate seizure precautionsforthe client.
11. a nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Remove the client’srestraint every 4hr
B. Document the client’s condition every 15 min
C. Attach the restrain to the bed’sside rails
D. Request a PRN restrain prescription for clients who are aggressive
12. A nurse isteaching 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. (Unable to read) for the unit
C. Prioritiesstaff request over client needs.
D. Providesroutine client care and documentation.
13. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and
reportsthat she has been following her (unable to read) care. The nurse should identify
which of the following findingsindicates a need to revise the client’s plan of care.
A. Serum sodium 144 mEq/
B. (Unable to read)
C. Hba1c 10 %
D. Random serum glucose 190 mg/dl.
14. A nurse in a provider’s office isreviewing the laboratory results of a group of clients. The
nurse should identify that which of the following sexually transmitted infectionsis a [Show Less]