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
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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
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
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