- The nurse is completing the admission assessment of a 3-year old who is
admitted with bacterial meningitis and hydrocephalus. Which assessment
finding is evidence that the child is experiencing increased intracranial
pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope: B. Sluggish and unequal pupillary
responses - A client with acute pancreatitis is admitted with severe, piercing abdominal
pain and an elevated serum amylase. Which additional information is the
client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.: A. Abdominal pain
decreases when lying supine - A child newly diagnosed with sickle cell anemia (SCA) is being discharged
from the hospital. Which information is most important for the nurse to
provide the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family: A. Instructions about
how much fluid the child should drink daily - To auscultate for a carotid bruit, the nurse places the stethoscope at what
location. (Select the location on the image with a red dot).: I placed the red
dot on the base of the neck on the right side - After receiving report on an inpatient acute care unit, which client should
the nurse assess first?
A. The client with an obstruction of the large intestine who is experiencing
abdominal distention
B.The client who had surgery yesterday and is experiencing a paralytic ileus
with absent bowel sounds
C.The client with a small bowel obstruction who has a nasogastric tube that
is draining greenish fluid
D.The client with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity: D. The client with a bowel obstruction due to a volvulus who
is experiencing abdominal rigidity
- A teenager presents to the emergency department with palpitations after
vaping at a party. The client is anxious, fearful, and hyperventilating.The
nurse anticipates the client developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis: D. Respiratory alkalosis - A client with dyspnea is being admitted to the medical unit.To best prepare
for the client’s arrival, the nurse should ensure that the client’s bed is in
which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers: Fowlers - The nurse is taking the blood pressure measurement of a client with
Parkinson’s disease. Which information in the client’s admission assessment is relevant to the nurse’s plan for taking the blood pressure reading?
(Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling: A. Frequent syncope
C. Flat affect
D. Blurred vision - While caring for a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare
provider, the nurse should review which of the client’s laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level: B. Culture for sensitive organisms - A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care
to the child, the nurse begins talking with his preadolescent brother who
rescued the child from the swimming pool and initiated resuscitation. The
nurse notices the older boy becomes withdrawn when asked about what
happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C.Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions: B. Ask the older brother
how he felt during the incident
- A male client with cirrhosis has jaundice and pruritus. He tells the nurse
that he has been soaking in hot baths at night with no relief of his discomfort.
Which action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion after
soaking
B. Obtain a PRN prescription for an analgesic that the client can use for
symptom relief
C. Suggest that the client take brief showers and apply oil-based lotion after
showering
D. Explain that the symptoms are caused by liver damage and cannot be
relieved: A. Encourage the client to use cooler water and apply calamine lotion
after soaking - An older client with a long history of coronary artery disease (CAD),
hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress.The healthcare provider prescribes
furosemide IV. Which therapeutic response to furosemide should the nurse
expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload: B. Reduced preload - Which intervention should the nurse include in the plan of care for a child
with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light: B. Minimize the amount of
stimuli in the room - An adolescent who was diagnosed with diabetes mellitus Type 1 at the
age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?