Transition Test 2
1. The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?
" I don't need to use my walker to get to the bathroom."
1. A couple presents to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?
"Do you plan to have any other children?"
The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client indicates that further teaching is necessary?
"I can take aspirin or my antihistamine if I need it."
The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching?
"I need to constantly watch for signs of low blood sugar."
1. A nurse is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?
"I need to lie flat on my back to perform the procedure."
1. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?
"I should avoid exercise because of the negative effects on insulin production."
The nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.
"I should decrease my oral fluids when i start this medication.", "I should report headache and drowsiness to my doctor since these symptoms could be related to my desmopressin."
1. The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction?
"I should not use insect repellent because it will attract ticks."
1. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction?
"I should take hot baths because they are relaxing."
1. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?
"I will maintain strict bed rest throughout the remainder of the pregnancy."
The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?
"I will notify my primary care provider if my blood glucose level is higher than 250 mg/dL."
1. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?
"It connects the umbilical vein to the inferior vena cava."
1. A nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?
"It promotes the fertilized ovum's normal implementation in the top of the uterus."
1. A 55-year-old male client confides to the nurse that he is concerned about his sexual function. What is the nurse's best response?
"Please share with me more about your concerns."
A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?
"The medication will kill the bacteria and stop the acid production."
1. A pregnant client in the first trimester calls the nurse at the health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?
"The vaginal discharge may be bothersome, but is a normal occurrence."
1. A nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
"You will need to bottle-feed your newborn."
1. A nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply.
"the ductus arteriosus allows blood to bypass the fetal lungs.", "One vein carries oxygenated blood from the placenta to the fetus.", "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."
The rural emergency department nurse is triaging victims at the site of a disaster. The victims are tagged using a color code system. Which client should be evacuated first? Rank in order of priority
1) the client assigned a red tag who is alert and diagnosed with a sucking chest wound 3)the client assigned a yellow tag whose abdomen is hard and tender to the touch 2)the client assigned a green tag who cannot stop crying and can't answer questions 4) the client assigned a black tag with full-thickness burns on more than 60% of the body 5) the client assigned a white tag who has no injuries and is comforting the victims
1. The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply.
Ballottement, Chadwick's sign, uterine enlargement, positive pregnancy test
1. A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?
G=2, T=1, P=0, A=0, L=1
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis. The initial blood glucose level is 950 mg/dL. A continuous IV infusion of short acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL. The nurse should next prepare to administer which medication?
IV fluids containing dextrose
1. A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual cycle was October 19, 2019. Using Naegele's rule, which expected date of delivery should the nurse document in the client's chart?
July 26, 2020
The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first?
Morphine IV infusion to the client who is 8 hours postoperative and is reporting pain, rating it as 7
The RN charge nurse is making shift assignments to the surgical staff, which consists of two RNs, two LPNs, and two UAPs. Which assignment would be most appropriate for the RN charge nurse to make?
Request the LPN to complete the admission for a new client
The RN staff nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention?
The UAP assists a client who received an IV narcotic analgesic 30 min ago to ambulate in the hall
1. Which behavior warrants intervention by the clinical manager in the medical-surgical outpatient clinic?
The UAP discussing a client's condition in the waiting room
The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?
a heart rate that is 90 beats per minute and irregular
1. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?
a normal test result
1. The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.
a primigravida with abruptio placenta, a gravida 2 who has just been diagnosed with dead fetus syndrome, a primigravida at 29 wks of gestation who was recently diagnosed with gestational hypertension
1. A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?
a temporary worsening of the condition
1. The nurse is preparing to administer medications. Which medication should the nurse administer first?
acetaminophen due in 5 minutes
1. The client is diagnosed with scleroderma. Which intervention should the nurse anticipate be prescribed?
administer corticosteroids as prescribed for inflammation
1. A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply.
administer oxygen to the client, notify the HCP and RRT, stop dialysis and turn the client on the left side with head lower than feet
31. The nurse in the labor room is caring for a client in the active stage of first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?
administer oxygen via face mask
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.
administer stool softeners as prescribed, encourage a high fiber diet to promote bowel movements without straining, apply cold packs to the anal rectal area over the dressing until the packing is removed
1. The RN primary nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the RN assign to the LPN?
administer the client's anticoagulant subcutaneously
1. A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?
affect is flat, with periods of emotional liability
1. A nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid. Select all that apply.
allows for fetal movement, surrounds cushions and protects the fetus, maintains the body temperature of the fetus, can be used to measure fetal kidney function
1. The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first?
an anticholinesterase medication to a client diagnosed with myasthenia gravis
1. A nurse is providing instructions to a pregnant client who is scheduled to undergo an amniocentesis. What instruction should the nurse provide?
an informed consent needs to be signed before the procedure
1. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?
assess the baseline fetal heart rate
1. The UAP reports to the RN primary nurse that the client's urine output has bright red blood. Which intervention should the RN implement first?
assess the client's urine specimen and complete a renal assessment
1. Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
blood urea nitrogen level of 25 mg/dL
1. The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.
bright red vaginal bleeding, soft relaxed nontender uterus, fundal height may be greater than expected for gestational age
A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?
capillary refill is less than 2 seconds
1. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply.
check the level of the drainage bag, reposition the client to their side, place the client in good body alignment, check the peritoneal dialysis system for kinks
A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment?
checking the frequency and consistency of bowel movements
1. The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully?
consistently uses adaptive equipment in dressing self
28. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?
delivery of the fetus
1. A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
direct bilirubin level of 2 mg/dL
1. A nurse is assisting a client undergoing induction of labor at 41 weeks gestation. The client's contractions are moderate and occurring every 2-3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120-122 beats per minute for the past hour. What is the priority nursing action?
discontinue the infusion of oxytocin
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?
document the findings
A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. What should the school nurse instruct the child to do?
eat a small box of raisins or drink a cup of orange juice before practice
1. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding?
elevated creatinine level
The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?
encourage the child to drink liquids
1. A nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
encouraging fluids
1. A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?
enlarged lymph nodes
1. A nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?
evidence of bleeding, such as in the gums, petechiae, and purpura
1. A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
exhaling during repositioning
1. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider?
fetal heart rate of 180 beats per minute
The clinic nurse reviews the record of an infant and notes that the primary health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?
foul-smelling ribbon-like stools
The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.
give the child a teaspoon of honey, prepare to administer glucagon subcutaneously if unconsciousness occurs
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is begin assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.
gray-blue color at the flank, abdominal guarding and tenderness, left upper quadrant pain with radiation to the back
1. The clinic nurse is making assignments for the large family practice clinic. Which task should be assigned to a staff nurse who is 4 months pregnant?
have the staff nurse answer the telephone calls from clients
1. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?
headache, deteriorating level of consciousness, and twitching
1. A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?
hematocrit of 33%
1. The nurse discusses plan for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply.
hemodialysis, kidney transplant, bilateral nephrectomy
1. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?
hemorrhage
1. A home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia?
hypertension
A client with a diagnosis of Addisonian crisis is being admitted to the ICU. Which findings will the interprofessional health care team focus on? Select all that apply.
hypotension, hyperkalemia
1. A nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which should the nurse expect to note specifically in this disorder?
increased calcium level
1. The nurse is caring for the client with increased intracranial pressure. Then nurse should note which trend in vital signs if the intracranial pressure is rising?
increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
1. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?
inform the client that these contractions are common and may occur throughout the pregnancy
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion and has a serum sodium of 118 mEq/L. Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply.
initiate an infusion of 3% NaCl, restrict fluids to 800mL over 24 hours, administer a vasopressin antagonist as prescribed
1. Which nursing task should the RN staff nurse on the renal unit assign to the LPN?
insert an indwelling urinary catheter before surgery
1. The RN primary nurse is caring for clients on the renal unit. Which task is most appropriate for the RN to delegate to the UAP?
instruct the UAP to calculate the clients' urinary intake and output
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse should immediately prepare to initiate which anticipated health care provider's prescription?
intravenous infusion of normal saline
1. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.
loosening restrictive clothing, removing the pillow and raising the padded side rails, positioning the client to the side, if possible, with the head flexed forward
The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.
maintain NPO status, encourage coughing and deep breathing, give hydromorphone intravenously as prescribed for pain
A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?
maintain a patent airway
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
metabolic alkalosis
1. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 101.2. Which nursing action is most appropriate?
notify the HCP
1. The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats per minute. On the basis of this finding, what is the priority nursing action?
notify the obstetrician
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate?
notify the primary health care provider
1. A maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription?
obtain equipment for a manual pelvic examination
1. The nurse is conducting a history and monitoring lab values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply.
pathological fracture, urinalysis positive for nitrites, serum creatinine level of 2 mg/dL
1. The RN staff nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks can the RN staff nurse delegate to the UAP? Select all that apply.
perform the client's morning hygiene care, ambulate the client to the bathroom, obtain the client's routine vital signs
1. A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?
place the client in Trendelenburg's position
1. A client with acute kidney injury has a serum potassium level of 7.0 mEq/L. The nurse should plan which actions as a priority? Select all that apply.
place the client on a cardiac monitor, notify the HCP, review the client's medications to determine if any contain or retain potassium
A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting glucose level has been 180-200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia?
prednisone
The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data should the nurse expect to obtain when asking the parents about the child's symptoms?
projectile vomiting
1. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan?
protecting the client from infection
Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply.
providing a low fat well balanced diet, teaching the child effective hand washing techniques, instructing the parents to avoid administering medications unless prescribed
1. A client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?
providing information, giving positive feedback, and encouraging relaxation
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider?
purple discoloration of the stoma
A client who uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?
relief of epigastric pain
The nurse has just administered ibuprofen to a child with a temperature of 102 F. The nurse should also take which action?
remove excess clothing and blankets from the child
The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?
rice
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply.
shakiness, palpitations, lightheadedness
1. A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result?
slurred speech
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?
sweating and pallor
1. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?
taking medications as scheduled
The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 70 mg/dL, temperature of 101 F, pulse of 82 beats per minute, respirations of 20 breaths per minute, and blood pressure of 118/68 mm Hg. Which finding would be the priority concern to the nurse?
temperature
1. The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse?
the 24 year old who had a circumcision and is being prepared for discharge
1. What action by the LPN requires intervention by the critical care RN charge nurse?
the LPN has the trough drawn after hanging the aminoglycoside
1. The RN primary nurse and UAP are caring for a client diagnosed with right-sided paralysis. Which action by the UAP requires the RN to intervene?
the UAP places her hand under the client's right axilla to help the client move up in bed
1. A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks' gestation because of which factor?
the appearance of the fetal external genitalia
1. A home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider?
the client complains of headache and blurred vision
1. The nurse has just received the shift report. Which client should the nurse assess first?
the client diagnosed with a C-6 spinal cord injury who has autonomic dysreflexia
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report?
the client diagnosed with acute pyelonephritis who has nausea/vomiting and is dehydrated
1. The critical care RN charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed orientation?`
the client diagnosed with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at bedside
1. The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first?
the client diagnosed with benign prostatic hypertrophy who has blood oozing from the intravenous site
1. The nurse is caring for clients on a renal unit and making assignments for the day. Which client should the nurse assess first?
the client diagnosed with nephrolithiasis who has hematuria and is complaining of pain rating it as a 9
1. The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first?
the client diagnosed with renal vein thrombosis who has a heparin drip infusion and a PTT of 92
1. The critical care nurse is caring for a client diagnosed with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse?
the client extends the upper and lower extremities in response to painful stimuli
1. The nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?
the client is measuring normal for gestational age
1. The charge nurse has received laboratory data for clients on the medical unit. Which client would require intervention by the charge nurse?
the client receiving phenytoin who has serum levels of 24 mcg/dL
1. The RN charge nurse is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished orientation?
the client with a cystectomy who had a creation of an ileal conduit
1. The charge nurse is making client assignments for a neurological medical floor. Which client should be assigned to the most experienced nurse?
the elderly client who is experiencing a stroke in evolution
1. A nurse evaluates the ability of a hepatitis B- positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?
the mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding
The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease (GERD). Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?
thicken the feedings by adding rice cereal to the formula
1. A nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?
uterine tenderness
1. The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?`
variable decelerations
1. The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?
wearing a gown and gloves
1. A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?
white blood cell count 3000 mm
