Multiple All Systems

The nurse is reinforcing prior teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss? 1. Heart valve injury 2. Intellectual disability 3. Joint destruction 4. Recurrent pneumonia

Joint destruction

The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers? 1. Demonstrating adequate coping skills 2. Knowing how to keep blood sugars stable 3. Understanding how to perform meal planning 4. Understanding the need for periodic follow-up visits

Knowing how to keep blood sugars stable

The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation? 1. Bilateral bowlegs (genu varum) in a 15-monthold 2. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant 3. Lateral curvature to the spine noted on examination of a 10-year-old girl 4. Presence of an S3 heart sound in a 2-year-old

Lateral curvature to the spine noted on examination of a 10-year-old girl

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur 2. Loud machine-like murmur 3. Soft diastolic murmur 4. Systolic ejection murmur

Loud machine-like murmur

The nurse is caring for a 2-year-old who is receiving a saline enema for treatment of intussusception. Which client finding is most important to report to the supervisory registered nurse? 1. Passed a normal brown stool 2. Passed a stool mixed with blood 3. Stopped crying 4. Vomited a third time

Passed a normal brown stool

A client gives birth within an hour of arriving at the labor and delivery unit and delivers the placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline and boggy. Which action should the nurse take first? 1. Check for pooled blood under buttocks 2. Increase IV oxytocin infusion rate 3. Monitor blood pressure and pulse 4. Perform firm fundal massage

Perform firm fundal massage

The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk has a pink color. What is the nurse's initial action? 1. Apply oxygen and count respirations 2. Assess heart sounds for a murmur 3. Observe for expiratory grunting 4. Place infant skin-to-skin with mother

Place infant skin-to-skin with mother

A child with autism spectrum disorder is being admitted to a medical-surgical unit. Which is the most appropriate nursing action? 1. Placing the child in a private room away from the nurses' station 2. Placing the child in a private room near the playroom 3. Placing the child in a semi-private room near the nurses' station 4. Placing the child in a semi-private room with another child with autism spectrum disorder

Placing the child in a private room away from the nurses' station

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? 1. Ask about liver disease and give acetaminophen from the nurse's personal supply 2. Check for allergies to drugs before giving acetaminophen from hospital stock 3. Check the employee's blood pressure 4. Refer employee to the employee's health care provider

Refer employee to the employee's health care provider

During the client interview for a developmentally normal 18-monthold, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention? 1. Check the child for parasitic infections 2. Consult a pediatric nutritionist for suspected eating disorder 3. Notify the health care provider 4. Reinforce teaching about the toddler's nutritional needs

Reinforce teaching about the toddler's nutritional needs

The nurse reviews new laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the supervising registered nurse? 1. CD4 cell count of 500/mm in a client with HIV and oral candidiasis who is receiving PO fluconazole 2. Hemoglobin A1c of 7.3% in a client with type 2 diabetes and pneumonia who is receiving IV levofloxacin 3. Platelet count of 152,000/mm in a client with a venous thrombosis who is receiving a continuous heparin infusion 4. Serum glucose of 65 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition

Serum glucose of 65 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition

A nurse discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action? 1. Administer 100% oxygen 2. Auscultate the lungs 3. Place infant in knee-chest position 4. Suction the infant's mouth

Suction the infant's mouth

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5 T1 P2 A1 L2 . Which interpretation of this notation is correct? 1. The client had 1 birth at 37 wk 0 d gestation or beyond 2. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation 3. The client has 3 currently living children 4. The client is currently not pregnant

The client had 1 birth at 37 wk 0 d gestation or beyond

A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child's parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse? 1. The parent cannot stay at the hospital due to potential job loss if late for work 2. The parent does not seem to be concerned about the child's condition 3. The parent is single 4. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old

The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old

A 14-year-old is scheduled for surgery to treat scoliosis. The child will be hospitalized for about a week and then discharged home to recuperate for 3-4 weeks before returning to school. What is the best activity the nurse can recommend to promote age-specific growth and development during this time? 1. Attending selected after-school events and social activities 2. Keeping up with schoolwork . 3. Reading teen magazines 4. Visits from friends

Visits from friends

A distraught parent informs the nurse of bleeding in a 1-day-old girl. What is an appropriate response by the nurse after finding a small amount of bloody mucus in the newborn's diaper? . 1. "Laboratory work will need to be completed to determine your newborn's hormone levels." 2. "The health care provider will prescribe a dose of medication to stop the bleeding." 3. "We will continue to monitor the amount, color, and consistency of the drainage." 4. "What visitors have been present since the baby was born?"

We will continue to monitor the amount, color, and consistency of the drainage."

The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment? 1. "Bullying is a normal part of childhood growth and development." 2. "Children with physical disabilities are more vulnerable to bullying." 3. "Most children who are victims of a school bully do not tell an adult about it." 4. "The most common form of bullying is verbal aggression, such as insults and intimidation."

"Bullying is a normal part of childhood growth and development."

The nurse is reinforcing education to a prenatal client about the 1- hour glucose challenge test that will be performed at the next visit. Which client statement indicates a need for further education? 1. "Fasting is required before the 1-hour glucose challenge test." 2. "One blood sample is obtained at the end of the test." ( 3. "The test includes drinking a 50-g glucose solution." 4. "The test's purpose is to screen for gestational diabetes, not diagnose it."

"Fasting is required before the 1-hour glucose challenge test."

A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review? 1. "Give acetaminophen or ibuprofen every 6-8 hours to control fever." 2. "Give the infant frequent tepid sponge baths to control the fever." 3. "If the infant develops another seizure, wait 15 minutes to see if it subsides." 4. "Place ice bags under the arms and around the neck to control fever."

"Give acetaminophen or ibuprofen every 6-8 hours to control fever."

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse? 1. "Would you mind answering the lights anyway?" 2. "I need you to answer the lights because we want to provide good client care." 3. Say nothing and answer the lights, but write up a disciplinary action 4. Tell the UAP that this is unacceptable and speak to the nurse manager

"I need you to answer the lights because we want to provide good client care."

The nurse is reinforcing health promotion education to the parents of a toddler. Which statement by a parent requires the nurse to clarify teaching? 1. "I will offer my child options rather than asking yes or no questions." 2. "I will wait at least 15 minutes after a play period to offer a meal to my child." 3. "If my child is having a tantrum, I will have them sit in a quiet area for a short time-out." 4. "If my child refuses a meal, I will have them stay at the table until they eat half the food."

"If my child refuses a meal, I will have them stay at the table until they eat half the food."

A school-age child is brought to the emergency department due to nausea, vomiting, and severe right lower quadrant pain. The child's white blood cell count is 17,000/mm (17.0 x 10 /L). Which statement by the child is of most concern to the nurse? 1. "I am hungry and they will not let me eat." 2. "I don't like hospitals and I want to go home." 3. "I'm so tired." 4. "My belly doesn't hurt anymore.

"My belly doesn't hurt anymore.

The nurse is reinforcing teaching to the parent of a child diagnosed with ringworm. Which statement by the parent indicates a need for further teaching? 1. "Antifungal cream must be applied to all affected areas to eradicate ringworm from the body." 2. "Hand washing is very important as ringworm can be spread among humans and pets." 3. "My child has been infected by a worm and must be treated to rid it from the body." 4. "My child will be uncomfortable due to itching, but this is not a dangerous condition."

"My child has been infected by a worm and must be treated to rid it from the body."

The nurse is caring for a postoperative client with a Hemovac drain. Which task request is inappropriate for the nurse to make to the experienced unlicensed assistive personnel? 1. "Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client." 2. "Please measure the Hemovac drainage at 2:00 PM and let me know how much there was." 3. "Please record the amount of Hemovac drainage on the intake and output record at the end of the shift." 4. "Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught."

"Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client."

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I don't know why this is being reported. I told the health care provider (HCP) that it was an accident." What is the best response by the nurse? 1. "A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then." 2. "Did you ask the HCP why it is being reported?" 3. "Reporting your child's injuries is required by law. It is for your child's safety and protection." 4. "Your explanation of your child's injuries does not seem plausible."

"Reporting your child's injuries is required by law. It is for your child's safety and protection."

The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed? 1. "We will encourage extra fluid intake while our child is sick." 2. "We will increase the frequency of blood glucose checks." 3. "We will monitor our child's urine for ketones with each void." 4. "We will not administer insulin if our child is unable to eat."

"We will not administer insulin if our child is unable to eat."

A nurse is reinforcing education given to the parents of a child diagnosed with chronic allergic rhinitis that is triggered by household and environmental allergens. Which statements by the parents indicate that the teaching has been effective? Select all that apply. 1. "My wife plans to wipe down our child's furniture with a damp rag every other day." 2. "Our child needs plastic covers for the mattress and pillow." 3. "We must give away the family dog." 4. "We will keep the windows open during warm weather to air out the house." 5. "We will replace the carpet with hardwood floors throughout the house."

1. "My wife plans to wipe down our child's furniture with a damp rag every other day." 2. "Our child needs plastic covers for the mattress and pillow." 5. "We will replace the carpet with hardwood floors throughout the house."

Which statements related to ethical nursing practices are correct? Select all that apply. 1. Accountability is documenting that the nurse administered the wrong medication 2. Autonomy is informing the client of the decision the family made for the client 3. Confidentiality is respecting a client's request to keep suicidal ideation a secret 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5. Nonmaleficence is reporting abuse for a client with Alzheimer disease

1. Accountability is documenting that the nurse administered the wrong medication 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5. Nonmaleficence is reporting abuse for a client with Alzheimer disease

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second trimester teaching? Select all that apply. 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester ALL OF THEM

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time? 1. Ask the interpreter to explain the discussion 2. Confirm the client's consent with the interpreter, using gestures 3. Have the interpreter witness the signature 4. Indicate that the interpreter was used when witnessing the client's signature

1. Ask the interpreter to explain the discussion

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply. 1. Ask the parents if they would like to help bathe the infant 2. Discourage the parents from naming the infant 3.Discuss the importance of organ donation with the parents 4. Encourage the parents and family members to hold the infant 5. Offer to obtain handprints, footprints, and photographs of the infant

1. Ask the parents if they would like to help bathe the infant 4. Encourage the parents and family members to hold the infant 5. Offer to obtain handprints, footprints, and photographs of the infant

The nurse assessing a 2-year-old should expect the child to be able to perform which actions? Select all that apply. 1. Build a tower with blocks 2. Draw a square . 3. Hop on one foot 4. Say own name 5. Walk without help

1. Build a tower with blocks 4. Say own name 5. Walk without help

A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply. 1. Chronic hypoxemia 2. Diabetes insipidus 3. Frequent respiratory infections 4. Obesity 5. Vitamin deficiencies

1. Chronic hypoxemia 3. Frequent respiratory infections 5. Vitamin deficiencies

Which are appropriate examples of cost-effective care? Select all that apply. 1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing 3. Returning opened, unused supplies from a client's room to the central supply room 4. Reusing a tourniquet for multiple clients unless it is visibly soiled 5. Using remaining sterile saline in a bottle opened 48 hours ago before discarding

1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? Select all that apply. 1. Do not continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse 4. Say nothing but watch for impaired behavior 5. Tell the oncoming nurse that he/she is not fit for duty

1. Do not continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse

A nurse is discussing the fine motor abilities of a 10-month-old infant with the infant's parent. Which are developmentally appropriate skills for an infant of this age? Select all that apply. 1. Grasps a small doll by the arm 2. Stacks 3 wooden blocks 3. Transfers small objects from hand to hand 4. Turns single pages in a book 5. Uses a basic pincer grasp

1. Grasps a small doll by the arm 3. Transfers small objects from hand to hand 5. Uses a basic pincer grasp

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination 5. Unlicensed assistive personnel with a cold

1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply. 1. The nurse accepts money from the victim 2. The nurse does not accompany the victim on the ambulance 3. The nurse does not apply direct pressure to the artery 4. The nurse knows the victim from college 5. The victim dies after reaching the hospital

1. The nurse accepts money from the victim 3. The nurse does not apply direct pressure to the artery

A nurse is reinforcing information on formula preparation for a client with a newborn. Which statements by the client indicate proper understanding? Select all that apply. 1. "I can add water to the formula if my baby wants to eat more frequently." 2. "I must wash the top of the concentrated formula can before opening it." 3. "I shouldn't heat formula in the microwave for more than 1 minute." 4. "If my baby does not finish the bottle, the leftover milk should be refrigerated. 5. "Prepared formula should be kept in the refrigerator and discarded after 48 hours."

2. "I must wash the top of the concentrated formula can before opening it." 5. "Prepared formula should be kept in the refrigerator and discarded after 48 hours."

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. 1. Client admitted with white blood cell count of 28,000 mm (28.0 × 10 /L) and dies from sepsis 2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 3. Client refuses pneumonia vaccination and contracts pneumonia 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 5. Provider was not notified of client's positive blood culture results

2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 5. Provider was not notified of client's positive blood culture results

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply. 1. Client diagnosed with lumbar spinal cord compression has paraplegia 2. Client's Glasgow Coma Scale (GCS) score is 3 3. Client is refusing a life-saving treatment due to religious beliefs 4. Client with intracerebral hemorrhage has aphasia 5. Oriented client has cancer and is on a ventilator

2. Client's Glasgow Coma Scale (GCS) score is 3 4. Client with intracerebral hemorrhage has aphasia

The nurse is obligated to make a report for which situations? Select all that apply. 1. Report to a client's employer that the client had a car crash while intoxicated 2. Report to the authorities of a death by suicide on the unit 3. Report to the client's spouse that the client has a reportable sexually transmitted disease 4. Report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse 5. Report to the supervisor that a health care provider has the smell of alcohol on the breath

2. Report to the authorities of a death by suicide on the unit 4. Report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse 5. Report to the supervisor that a health care provider has the smell of alcohol on the breath

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply. 1. A visitor talking in the waiting room states that the client has alcoholism 2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home 3. The nursing assistant tells a client that the hospital roommate went for a gallbladder test 4. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions 5. Two LPNs are discussing a possible cure for AIDS on a crowded elevator

2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home 3. The nursing assistant tells a client that the hospital roommate went for a gallbladder test

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia? 1. 1-month-old infant born at term gestation who exclusively breastfeeds 2. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula 3. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk 4. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal

3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk

The nurse is providing teaching to the parents of a 1-year-old who was just prescribed a 10-day course of amoxicillin for acute otitis media. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply. 1. "Give your child over-the-counter decongestants to help speed up recovery." 2. "If your child develops loose stools, please discontinue the antibiotic." 3. "Return to the clinic if your child does not improve within 48-72 hours." 4. "Stop administering the amoxicillin if your child is feeling better in 5-7 days." 5. "Your child may need a hearing screening after the ear infection has resolved."

3. "Return to the clinic if your child does not improve within 48-72 hours." 5. "Your child may need a hearing screening after the ear infection has resolved."

The nurse is contributing to the plan of care for a client with diabetes who reports breast tenderness, vaginal discharge, and urinary frequency. Which action is most important to include in the plan of care? 1. Ask if the client performs breast self-exams 2. Ask the client about characteristics of vaginal discharge 3. Determine the date of the client's last menstrual period 4. Review the client's home blood sugar logs

3. Determine the date of the client's last menstrual period

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply . 1. Avoid intake of dairy products 2. Drink large amounts of fluid with meals 3. Eat several small meals each day 4. Eliminate fried, fatty foods 5. Lie down on the left side after meals

3. Eat several small meals each day 4. Eliminate fried, fatty foods

The practical nurse (PN) is assisting the registered nurse (RN) to care for a client receiving oxytocin for induction of labor. Which of the following actions by the PN are appropriate during oxytocin infusion? Select all that apply. 1. Assess deep tendon reflexes every hour 2. Assist RN to initiate intermittent fetal monitoring 3. Evaluate fluid intake and output every 4 hours 4. Notify RN if >5 contractions occur in 10 minutes 5. Obtain blood pressure with each oxytocin dose change

3. Evaluate fluid intake and output every 4 hours 4. Notify RN if >5 contractions occur in 10 minutes 5. Obtain blood pressure with each oxytocin dose change

The nurse is caring for an infant with osteogenesis imperfecta admitted with a new fracture. The client also has old fractures in multiple stages of healing but no bruising, abrasions, or redness of the skin. Which nursing intervention should be included in the plan of care? 1. During diaper changes, carefully lift the infant by the ankles 2. Lift from under the arms when picking up the infant 3. Obtain blood pressure manually to avoid cuff over-tightening 4. Request a social work consultation to assess for child abuse

3. Obtain blood pressure manually to avoid cuff over-tightening

The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply. 1. Dodgeball 2. Reading a book 3. Stationary bicycling 4. Swimming 5. Yoga

3. Stationary bicycling 4. Swimming 5. Yoga

The nurse preceptor should intervene if the graduate practical nurse performs which action when caring for a jaundiced newborn being treated with phototherapy? 1. Allowing the parents to feed the newborn 2. Applying a shirt while the newborn is exposed to phototherapy 3. Assessing the temperature of the incubator while the newborn is inside 4. Covering the newborn's eyes with protective shields

Applying a shirt while the newborn is exposed to phototherapy

During the charge nurse's morning rounds, a client says, "I hope you will take better care of me than the nurse I had last night." What should be the charge nurse's initial response? 1. Apologize for the previous nurse's treatment 2. Ask the client to describe what happened last night 3. Explain that the night nurse was probably busy 4. Reassure the client that things will be better today

Ask the client to describe what happened last night

A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? 1. Advise the parent to give a pacifier whenever the infant cries 2. Ask the parent to describe what is done to "keep the baby quiet" 3. Assess the infant's pattern and frequency of crying 4. Explore the parent's support system

Assess the infant's pattern and frequency of crying

The nurse working on a pediatric oncology unit recognizes which as a personal coping strategy for remaining effective when caring for dying children? 1. Attending a child's memorial service 2. Avoiding expressing personal feelings of grief or loss directly with the family 3. Ending personal contact with the deceased's family members after they leave the hospital 4. Increasing length of daily exercise routines

Attending a child's memorial service

Which meal should the nurse recommend for a pregnant client at 13 weeks gestation? 1. Baked chicken, turnip greens, peanut butter cookie, and grape juice 2. Baked swordfish, fries, baked apples, and fat free milk 3. Chilled ham and cheese sandwich, broccoli, orange slices, and water 4. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water

Baked chicken, turnip greens, peanut butter cookie, and grape juice

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority? 1. Blood pressure 2. Hematuria 3. Intake and output 4. Peripheral edema

Blood pressure

The nurse supervisor tells the practical nurse (PN) to go to the telemetry unit ("float") as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the PN? 1. Clarify the skills/knowledge that the nurse is able/unable to perform 2. Read the policy and procedure book for the unit before providing care 3. Refuse to go due to concerns about client safety 4. Tell the supervisor to send someone else instead

Clarify the skills/knowledge that the nurse is able/unable to perform

The nurse working on a medical-surgical unit receives change-of shift report on several clients. Which client should the nurse see first? 1. Client after a colonoscopic polypectomy today with abdominal cramping and a small amount of rectal bleeding 2. Client after a laparoscopic inguinal hernia repair yesterday who reports urinary hesitancy while voiding 3. Client after a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement 4. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)

Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)

A nurse receives information in a change of shift report. Which client is the priority? 1. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum 3. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul smelling, fatty stools

Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? 1. Client with blood pressure of 90/70 mm Hg and deviated trachea 2. Client with concussion who was unconscious for 5 minutes 3. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg 4. Client with pain at the thoracic spine and complete paralysis of both legs

Client with blood pressure of 90/70 mm Hg and deviated trachea

The nurse is caring for a 7-year-old with sickle cell crisis. The client is short of breath and vomiting and has severe generalized body and joint pains. Which assessment finding requires the most immediate intervention? 1. Blood work showing anemia 2. Enlarged spleen on palpation 3. Right arm weakness 4. Swelling of hands and feet

Enlarged spleen on palpation

An overweight toddler is diagnosed with iron deficiency anemia. Which is the most likely explanation for the anemia? 1. Excessive intake of meat products 2. Excessive intake of milk 3. Gastrointestinal blood loss 4. Impaired iron transfer from the mother

Excessive intake of milk

The registered nurse is preparing to administer oxytocin to induce labor in a client. The practical nurse assists the registered nurse and recognizes that the oxytocin infusion can lead to which of the following conditions? 1. Decreased postpartum hemorrhage 2. Delayed milk production 3. Fetal distress and cesarean birth 4. High risk of placenta previa

Fetal distress and cesarean birth

The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? 1. Fever 2. Irritability 3. Joint pain 4. Skin peeling

Fever

A nurse is reviewing the laboratory values of a 3-year-old with nephrotic syndrome. The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome? Look at exhibit for additional information. 1. Glomerular injury 2. Hepatic impairment 3. Inherited hypercholesterolemia 4. Malnutrition EXHIBIT: Laboratory results Serum albumin: 2.0 g/dL (20 g/L) Serum total cholesterol: 275 mg/dL (7.1 mmol/L) Urinalysis: protein3+

Glomerular injury

Which infant should be the nurse's priority for monitoring and intervention? 1. Infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min 2. Infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL(2.2 mmol/L) 3. Infant delivered vaginally 30 minutes ago who has bilateral crackles 4. Infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)

Infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL(2.2 mmol/L)