7
A mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A farm set 4. A jack set with marbles
1. A wagon
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child 2. Encourage play with other children of the same ae 3. Advise the family to visit only during the scheduled visiting hours 4. Provide a private room, allowing the child to bring favorite toys from home
1. Encourage the child's parents to stay with the child
The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? 1. HOB 30-45 degrees 2. Trendelenburg 3. Reverse Trendelenburg 4. Flat
1. HOB 30-45 degrees
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/min 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all four quadrants
1. Increasing restlessness
The nurse is caring for client with meningitis and implements which transmission precautions for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room
1. Private room or cohort client
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respirations in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration.
1. Rhythmic respirations with periods of apnea
The nurse is caring for a client immediately after the removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/min 4. A few basilar lung crackles on the right
1. Stridor
The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? 1. The child has the ability to think abstractly 2. The child begins to understand the environment 3. The child is able to classify, order, and sort facts 4. The child learns to think in terms of past, present, and future
1. The child has the ability to think abstractly
The nurse has just reassessed the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6 degrees C (99.6 degrees F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing
1. Urinary output of 20 mL/hr
The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? 1. Allow the bottle if it contains juice. 2. Allow the bottle if it contains water. 3. Do not allow the child to have the bottle. 4. allow the bottle during naps but not at bedtime.
2. Allow the bottle if it contains water.
The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the IV line without the use of a pump 2. Contact the electrical maintenance department for assistance 3. Plug in the pump cord in the available plug about the room sink 4. Use an extension cord from the nurses lounge for the pump plug.
2. Contact the electrical maintenance department for assistance
The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? 1. Check for medication interactions 2. Determine whether there are medication duplications 3. Call the prescribing health care provider and report polypharmacy 4. Determine whether a family member supervises medication administration
2. Determine whether there are medication duplications
The nurse is monitoring a 3 month old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids 2. Document the finding 3. Notify the health care provider 4. Elevate the head of the bed to 90 degrees
2. Document the finding
The nurse assesses the vital signs of a 12 month old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen 2. Document the findings 3. Notify the health care provider 4. Reassess the respiratory rate in 15 minutes
2. Document the findings
A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Sim's position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow
2. Lying in bed on the unaffected side
The nurse is caring for a client who is 1-day post-operative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated
2. On the nonoperative side with the legs abducted
The nurse obtains a prescription from a healthcare provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the clients skin.
2. Safely securing the safety device straps to the side rails
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin
2. Serous drainage
The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1. Test the corneal reflex 2. Test the 6 cardinal positions of gaze 3. Test visual acuity, using the snellen eye chart 4. Test sensory eye function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin
2. Test the 6 cardinal positions of gaze
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "if it's any help, everyone is nervous before surgery" 2. "I will be happy to explain the entire surgical procedure to you" 3. "Can you share with me what you've been told about your surgery" 4. Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"
3. "Can you share with me what you've been told about your surgery"
The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim three times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime."
3. "I drink hot chocolate before bedtime."
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "aspirin can cause bleeding after surgery" 2. "Aspirin can cause my ability to clot blood to be abnormal" 3. "I need to continue to take the aspirin until the day of surgery" 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery"
3. "I need to continue to take the aspirin until the day of surgery"
While performing a cardiac assessment on a client with a incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. A blowing or swooshing noise 4. Abrupt, high-pitch snapping noise
3. A blowing or swooshing noise
The nurse is providing an educational session to new employees, and the topic is because of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse? 1. A man who has moderate hypertension 2. A man who has newly diagnosed cataracts 3. A woman who has advanced Parkinson's disease 4. A woman who has early diagnosed lyme disease
3. A woman who has advanced Parkinson's disease
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help 2. Extinguish the fire 3. Activate the fire alarm 4. Confine the fire by closing the room door.
3. Activate the fire alarm
The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? 1. Position the client supine to assist in medication absorption 2. Aspirate the nasogastric tube after medication administration to maintain patency 3. Clamp the nasogastric tube for 30 to 60 min following administration of the medication 4. Change the suction setting to low intermittent suction for 30 min after medication administration
3. Clamp the nasogastric tube for 30 to 60 min following administration of the medication
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in blood pressure or pulse
3. Have the client void immediately before going into surgery
The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. Which should the nurse tell the UAP about older clients with hearing loss? 1. They are often distracted 2. They have middle ear changes 3. They respond to low-pitched tones 4. They develop moist cerumen production
3. They respond to low-pitched tones
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished.
3. Wheezes
The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book
4. Crayons and a coloring book
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy
4. Obtain a telephone consent from a family member, following agency policy
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Stay very still 2. Exhale very quickly 3. Inhale and exhale quickly 4. Perform the Valsalva maneuver
4. Perform the Valsalva maneuver
The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? 1. Insert the tube quickly 2. Notify the health care provider immediately 3. Removes the tube and reinsert it when the respiratory distress subsides 4. Pull back on the tube and wait until the respiratory distress subsides.
4. Pull back on the tube and wait until the respiratory distress subsides.
The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1. "I should sleep on my left side" 2. "I should sleep on my right side" 3. "I should sleep with my head flat" 4. "I should not wear my glasses at any time"
1. "I should sleep on my left side"
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible 2. Keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees
4. The best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees
The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? 1. Allow the newborn infant to signal a need 2. Anticipate all needs of the newborn infant 3. Attend to the newborn infant immediately when crying 4. Avoid the newborn infant during the first 10 minutes of crying
1. Allow the newborn infant to signal a need
The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin
1. Crusting
4. Avoid the newborn infant during the first 10 minutes of crying The nurse notes that a 6-year old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take? 1. Report the observation to the health care provider 2. Move the objects in the child's direct field of vision 3. Teach the child how to visually scan the environment 4. Provide additional lighting for the child during play activities
1. Report the observation to the health care provider
A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to this stage of development? 1. This stage is associated with toilet training 2. This stage is characterized by the gratification of self 3. This stage is characterized by a tapering off of conscious biological and sexual urges 4. This stage is associated with pleasurable and conflicting feelings about the genital organs
1. This stage is associated with toilet training
The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms 2. Activate the emergency response plan 3. Obtain additional supplies from the central supply department 4. Obtain additional nursing staff to assist in treating casualties
2. Activate the emergency response plan
Which car safety device should be used for a child who is 8 years old and 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear facing convertible seat 4. Front facing convertible seat
2. Booster seat
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1. Do nothing because this is an expected finding 2. Check for an air leak, because the bubbling should be intermittent 3. Increase the suction pressure so that the bubbling becomes vigorous 4. Clamp the chest tube and notify the health care provider immediately
2. Check for an air leak, because the bubbling should be intermittent
A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is cause by which problem. 1. A defect in the cochlea 2. A defect in cranial nerve VIII 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex
3. A physical obstruction to the transmission of sound waves
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? 1. "you need to be concerned" 2. "you need to monitor the child's behavior closely" 3. "at this age, the child is developing his own personality" 4. "you need to provide more praise to the child to stop this behavior"
3. "at this age, the child is developing his own personality"
The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level? 1. Peer pressure 2. Social pressure 3. Parents' behavior 4. Punishment and reward
4. Punishment and reward
A 16 year old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read 2. Encourage the parents to room in with the client 3. Allow the family to bring in the client's computer games 4. Allow the client to interact with others in his or her (adolescent) same group
4. Allow the client to interact with others in his or her (adolescent) same group
The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? 1. Planning meals 2. Decorating the room 3. Scheduling hair-cut appointments 4. Allowing the client to choose social activities
4. Allowing the client to choose social activities
The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization preformed through the femoral vessel. The nurse checks the health care provider's prescription and plans to allow which client position or activity following the procedure? 1. Bed rest in high Fowler's position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees
4. Bed rest with head elevation no greater than 30 degrees
The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes the pH is 7.35. Based on this information which action should the nurse take at this time? 1. Retest the pH using another strip 2. Document the nasogastric tube is in the correct place 3. Check for placement by auscultating for air injected into the tube 4. Call the HCP and request a prescription for a chest radiograph
4. Call the HCP and request a prescription for a chest radiograph
The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes
4. Every 30 minutes
A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows
4. Supine, with the residual limb supported with pillows
The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway 2. Check tubes or drains for patency 3. Check the dressing to assess for bleeding 4. Assess the vital signs to compare with preoperative measurements
1. Assess the patency of the airway
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia" 2. "Close monitoring of your oxygen saturation will detect hypoxemia" 3. "Administration of intravenous fluids will prevent or treat fluid imbalance" 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism"
1. "Use of an incentive spirometer will help prevent pneumonia"
The 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess my children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."
1. "We will be sure not to leave hot liquids unattended."
The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising
1. After a shower or bath
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL 2. Sodium, 145 mEq/L 3. Serum creatinine, 0.8 mg/dL 4. Platelets, 210,000 cells/mm3
1. Hemoglobin, 8.0 g/dL
The nurse check for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding and reinstill the residual amount 2. Reinstill the amount and continue with administering the feeding 3. Elevate the client's head at least 45 degrees and administer the feeding 4. Discard the residual amount and proceed with administering the feeding
1. Hold the feeding and reinstill the residual amount
The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1. Left sim's position 2. Right sim's position 3. On the left side of the body, with the head of the bed elevated 45 degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees
1. Left sim's position
The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen
1. Prednisone
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position 2. Elevate and immobilize the grafted extremity 3. Maintain the grafted extremity in a flat position 4. Keep the grafted extremity covered with a blanket
2. Elevate and immobilize the grafted extremity
While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the HCP to reinsert the tube 2. Grasp the retention sutures to spread the opening 3. Call the respiratory therapy department to reinsert the tracheotomy 4. Cover the tracheostomy site with a sterile dressing to prevent infection
2. Grasp the retention sutures to spread the opening
the nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? 1. Decreased absorption of digoxin 2. Increased risk for digoxin toxicity 3. Decreased therapeutic effect of digoxin 4. Increased risk for side effects related to digoxin
2. Increased risk for digoxin toxicity
The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take.? 1. Call the HCP 2. Place the tube in a bottle of sterile water 3. Replace the chest tube system immediately 4. Place a sterile dressing over the disconnection site
2. Place the tube in a bottle of sterile water
The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into cup 4. Uses a knife for cutting food
2. Uses a cup to drink
The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid, twitching of the eyeballs 2. A dorsiflexion of the ankle and great toe with fanning of the other toes. 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed. 4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference
3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed.
The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position
3. Bed rest with elevation of the affected extremity
A mother calls a neighbor who is a nurse and tells the nurse that her 3 year old child has just ingested liquid furniture polish. The nurse would direct the mother to take the which immediate action? 1. Induce vomiting 2. Call an ambulance 3. Call the poison control center 4. Bring the child to the emergency department.
3. Call the poison control center
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low fowler's 3. High fowler's 4. Supine with the head flat
3. High fowler's
A spanish speaking client arrives at the triage desk in the emergency department and states to the nurse, "no speak english, need interpreter." which action is the best action for the nurse to take? 1. Have one of the clients family members interpret. 2. Have the spanish speaking triage receptionist interpret. 3. Page an interpreter from the hospitals interpreter services. 4. Obtain a spanish english dictionary and attempt to triage the client.
3. Page an interpreter from the hospitals interpreter services.
The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? 1. Mark the tube at 10 in 2. Mark the tube at 32 in 3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process 4. Place the tube at the tip of the nose and measure by extending the tube to earlobe and then don to the top of the sternum.
3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process
The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4. The clients upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.
3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield
4. Gloves, gown, goggles, and a mask or face shield
A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums. 3. Avoid letting the child nap during the day. 4. Inform the child of bedtime a few minutes before it is time for bed.
4. Inform the child of bedtime a few minutes before it is time for bed.
The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates a need for revision of the plan? 1. Wearing gloves when emptying the clients bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semi private room at the end of the hallway
4. Placing the client in a semi private room at the end of the hallway
The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? 1. Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." 2. Suggest to the client and daughter-in-law that they consider a nursing home for the client. 3. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. 4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens' center.
4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens' center.
