1. What instruction is most important for the nurse to provide a female client whohasjust
been diagnosed with trichomoniasis?
a. Avoid douching
b. Treat sexual partner (s) concurrently
c. Avoid using moist washcloths when bathing
d. Postpone becoming pregnant until the infection is treated
Correct B
2. A primigravida at term comes to the prenatal clinic and tells the nurse that she is having
contractions every 5 min. The nurse monitors the client for one hour, using an external fetal
monitor, and determines that the client’s contractions every 5 minutes. The nurse monitors
the client for one hour, using an external fetal monitor, and determines that the client’s
contractions are 7 to 15 minutes apart, lasting 20 to30 seconds, with mild intensity by
palpation. What action should the nurse take?
a. Tell the client to go directly to the hospital for admission to labor and delivery
foractive labor
b. Send the client home and instruct her to call the clinic when her contractions
occur5 minutes apart for one hour
c. Tell the client to check into the hospital within the next hour for evaluation of
possible urinary tract infection
Correct B
3. Which instruction should the nurse provide to an elderly client who is taking an
ACEinhibitor and a calcium channel blocker?
a. Wear long-sleeved clothing when outdoors
b. Report the onset of sore throat
c. Eat plenty of potassium-rich food
d. Change the position slowly
Correct D
,4. Assessment finding of a 3-hour-old newborn include: axillary temperature of 97.7 F,
heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42
breaths/min. Based on these findings, what action should the nurse implement?
a. Place a pulse oximeter on the heel
b. Swaddle the infant in a warm blanket
c. Record the findings on the flow sheet
d. Check the vital signs in 15 minutes
Correct C
5. A client admitted to the hospital for depression is escorted to a private room. Prior
to leaving the room, what intervention is most important for the nurse to implement?
a. Explain the programs guidelines
b. Search all personal belongings
c. Initiate psychosocial assessment
d. Review the healthcare’s provider’s prescription
Correct B
6. An experienced nurse tells the nurse-manager that working with a new graduate is
impossible because the new graduate will not listen to suggestions. The new graduate
comes to the nurse-manager describing the senior nurse’s attitude as challenging and
offensive. What action is best for the nurse manager to take?
a. Have both nurses meet separately with the staff mental health
consultant
b. Listen actively to both nurses and offer suggestions to solving dilemma
c. Ask the senior nurse to examine mentoring strategies used with the new
graduate
d. Ask the nurses to meet with the nurse-manager to identify ways of working
together
Correct D
, 7. Which nursing diagnosis has the highest priority when planning care for a client in
cardiogenic shock?
a. Risk for imbalance body temperature
b. Excess fluid volume
c. Fatigue
d. Ineffective Tissue Perfusion
Correct D
8. A client who had a cerebral vascular accident (CVA)
Is paralyzed on the left side of the body and has developed a Stage II pressure
ulcer on the left hip. Which nursing diagnosis describes this client’s current health
status?
a. Risk for impaired tissue integrity related to impaired physical mobility
b. Impaired skin integrity related to altered circulation and pressure
c. Ineffective tissue perfusion related to inability to move self in bed.
d. Impaired physical mobility related to the left side paralysis
Correct B
9. The nurse offers diet teaching to a female college student who was diagnosed with
iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What
nutrients should the nurse suggest this client eat to best meet her nutritional needs while
allowing her to adhere to a lacto-vegetarian diet?
a. Drink whole milk instead of skim milk to enhance the body’s production of amino
acids
b. Take vitamin K 10mg PO daily to enhance production of red blood cells
c. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
d. Combine several legumes and grains such as beans and rice to form
complete proteins
Correct D
10. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a
blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should
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