2 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?
Place the newborn 45 cm (18 in) from the light source
...
2 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?
Place the newborn 45 cm (18 in) from the light source
3 an assistive personnel tells the nurse that several client measurements were obtained with morning
vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60
5 A community health nurse recognizes that the teen pregnancy rate in the community has increased.
Which of the following program-planning strategies should the nurse implement first?
Arrange a meeting with teenage mothers who are high school students in the community
6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the
assistive personnel, which of the following task does the nurse direct the AP to complete first?
Place an NPO sign on the door of a client scheduled surgery
7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the
following nursing actions is appropriate?
Covering insertion site with a transparent dressing
8 A nurse is performing disaster triage following a natural disaster. Which of the following should the
nurse identify as the highest priority to receive care?
A client who has agonal respirations
9 A nurse is planning to provide community education about viral hepatitis. Which of the following
should the nurse plan to include in the teaching?
Series of four hepatitis vaccines is recommended to prevent viral hepatitis
10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the
following actions by nurse demarcates veracity?
The nurse explains the potential risks of treatment
11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last
time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the
client’s wishes. The nurse committed which of the following?
Battery
12 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI).
Which of the following assessment findings should the nurse report to the provider as a possible
indication of left-sided heart failure?
Bilateral lung crackles
13////
14 A nurse is caring for a group of clients. The nurse should request a referral for a speech language
pathologist for which of the following clients?
A client who has difficulty swallowing
15 A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has
major depressive disorder. Which of the following should the nurse include in the teaching?
A general anesthetic is administered prior to ECT treatments
16 A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess
the newborn for which of the following manifestations of neonatal abstinence syndrome
Tachypnea/irritability/tremors
17 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?
Hyperemesis
18 A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit.
The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has
selected. Which of the following actions is appropriate for nurse to take?
Ask the charge nurse to assign an experienced nurse to act as a resource
19 A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total
body radiation and intense chemotherapy. The client’s sibling comes visit but has obvious manifestations
of an upper respiratory infection. Which of the following nursing actions is appropriate at this time?
Allow the sibling to wave at the client through the window or door
20 A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central
venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer’s lactate at 150
mL per hr. prior to starting the infusion, which of the following actions should the nurse take?
Review the chest x-ray report
21 A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for
pancrealipase. Which of the following should the nurse include in the teaching?
Take with meals
22 A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The
nurse should expect which of the following laboratory values indicative of organ damage from the
overdose?
Alanine aminotransferase (ALT)
23 A nurse on an orthopedic floor is completing morning assessments on several clients. Which of the
following clients has the greatest risk for fat embolism syndrome (FES)?
A 24-year-old male who has a casted femur fracture
24 A nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her
father’s do-not-resuscitate request. Which of the following is a therapeutic response by the nurse?
“Tell me your feelings about your father’s prognosis”
25 A nurse is providing teaching to the parent of preschooler who was newly diagnosed with a latex
allergy. The nurse should discuss that a cross reaction may occur with which of the following foods?
Bananas
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