The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
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?
3. The...
,1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
A) Make certain 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?
A) 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?
C) 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?
A) "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?
A. Checking the client's 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?
C. "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:
B. 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:
B. Asking the ED physician to check the client Correct
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:
A. 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?
A. "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?
A. 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:
A. 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?
D) 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?
B) 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
B) An occupational therapist from the community center
16. A priority goal of involuntary hospitalization of the severely mentally ill client is
C) 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
A) 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
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