1.After listening to the parents reports and seeing the following pediatric clients, the nurse knows

1.After listening to the parent’s reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting?1-year-old with dyspnea, drooling, and a swollen tongue after eating part of a houseplant 2-year-old who is crying and has a large forehead hematoma after falling out of a chair 3-year-old with second degree burns on the face after pulling a cup of hot tea off the table 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree 2.The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate?Contact the client’s family and ask them to bring prepared food from home Inform the client that tube feedings will be initiated if the client refuses to eat Offer to taste the client’s food and drinks while the client observes Provide the client food in unopened single-serving packages 3.The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assess for allergies, explains the procedure to the client, and asks unlicensed personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used.Perform hand hygiene and open sterile urinary catheterization kit Apply sterile gloves and place fenestrated drape with shiny side down Use nondominant hand to grasp penis below glans Use dominant hand to cleanse meatus with cotton balls or swab stick Use dominant hand to insert catheter until urine return is observed Advance catheter to tubing bifurcation and inflate balloon 4.A client in cardiac arrest, and resuscitation efforts are in progress when the client’s spouse arrives. The client’s spouse insists on coming into the room. How should the nurse respond?Allow the spouse into the room and provide a chair Call the chaplain to sit with the spouse outside the room Have the unit secretary escort the spouse to the waiting room Tell the spouse that the resuscitation is too graphic to be witnessed 5.The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 103 F (38.8 C). Which new prescription from the health care provider should the nurse implement first?Administer ondansetron 4 mg IV push PRN for nausea or vomiting Document the occurrence and notify the hospital’s epidemiology team Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV Obtain blood culture and discontinue the central venous catheter 6.The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate?Client with blood loss anemia and client with intractable diarrhea Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting Client who had a bowel resection 1 day ago and client with asthma exacerbation Client who had a total hip arthroplasty 2 days ago and client with influenza

7.The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and looses a pulse. The client’s adult child states, “I changed my mind. Do whatever you can to save him!” Which intervention is most appropriate at this time?Call for help to initiate cardiopulmonary resuscitation.Call the health care provider to confirm the DNR status.Explain the client’s wishes to the client’s child.Offer to call the hospital chaplain to provide support.

8.The clinic nurse is assessing a client who is being treated for depression and suicidal ideation.Which client statement best indicates that the client is not currently at risk for suicide?“I lost my imipramine prescription. Could I have a refill?” “I plan to attend my granddaughter’s graduation next month.” “I seem to have a lot more energy since I started therapy.” “I will sign a ‘no-suicide’ contract at today’s appointment.” 9.The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescription, what is the volume of medication in milliliter (mL) that the child should receive with each dose?

Exhibit Acetaminophen: 15mg/kg/dose PO q6h PRN for temperature >101 F

Available concentration: Acetaminophen: 160 mg/5 mL oral suspension

• mL

10.The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing?BMI of 29.5 kg/m^2 Family history of osteoporosis History of a daily glass of wine Peripheral artery disease 11.Based on the nursing assessment progress notes, what is the correct tagging of the client’s pressure injury?Exhibit: Shallow, open area with clean, dark pink wound bed about 1 cm in diameter noted on coccyx.1300 Surrounding area is slightly hard and warm to touch with erythema. Foam dressing clean, dry, and intact. No drainage noted. Enterostomal consult made. RN Stage 1 Stage 2 Stage 3 Stage 4 12.A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client’s blood glucose level is 322 mg/dL (17.9 mmol/L), and the client’s breakfast tray has arrived. What action should the nurse take?Exhibit: Allergies: Penicillan Medications

NPH insulin: 25 units subcutaneously, twice daily 0730, 2100

Regular insulin: Per sliding scale, subcutaneously AC and HS

Sliding scale Blood Glucose Levels

<150 mg/dL 0 units 150-199 mg/dL 4 units 200-249 mg/dL 8 units 250-299 mg/dL 10 units 300-350 mg/dL 12 units >350 mg/dL 16 units and notify the health care provider Administer 25 units of NPH insulin now and then 12 units of regular insulin after the morning meal.Administer 37 units of insulin: 25 units of NPH insulin and 12 units of regular inulin in 2 separate injections.Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up NPH into the syringe first.Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first.

13.The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home heath care. Which condition presents the most concern as a safety hazard in the child’s home environment?Family lives in rural area.House is heated by wood-burning stove.House was built in 1983.Parents are unemployed with limited financial resources.

14.While the nurse is transporting a client to a new unit, the client’s chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse’s priority action?Activate the hospital emergency response system.Apply supplemental oxygen and quickly transport to the new unit.Check the client’s respiratory pattern and effort and oxygen saturation.Firmly cover the insertion site with the palm of a clean, gloved hand 15.The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy.What is the nurse’s priority intervention?

Exhibit: Labs

Sodium 140 mEq/L Potassium 3.0 mEq/L Magnesium 1.8 mg/dL Creatinine 1.1 mg/dL Medications Aspirin 81 mg PO daily Amiodarone 200 mg PO daily Potassium replacement protocol if serum potassium is less than 3.2 mEq/L Administer potassium replacement.Administer the dose of amiodarone.Attach cardiac defibrillator pads.Notify the health care provider.

16.A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?Client 2 months post heart transplant with sustained sinus tachycardia of 110/ min at rest Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain.Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F.Client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft.

17.There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first?Client who has partial-thickness burns on both hands.Client who is screaming and has a left lower arm laceration.Client with a broken. Protruding right tibia and gray, pulseless foot Client with a gaping head wound and Glasgow coma scale score of 3.

18.The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching?“Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel.” “Having a routine for bowel movements is important, but I should not wait if I feel the urge.” “I can use an over-the-counter laxative every other day if needed.” “I should try to eat more fruits and vegetables every day.” “Increasing my daily exercise level may help keep my bowel movements regular.” 19.The nurse receives handoff of care report on four clients. Which client should the nurse assess first?Client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls.Client who had an exploratory laparoscopy 2 hours ago and has absent bowel sounds and is reporting nausea.Client with diabetes mellitus who has a foot ulcer and is reporting feeling pins and needles in the lower legs.Client with Parkinson disease who has tremors while resting and developed black-colored urine after taking carbidopa/levodopa.

20.A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion?Administering high flow IV fluids.Applying oxygen via nasal cannula Maintaining strict bed rest Transfusing packed red blood cells 21.The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply.Instructs client that stockings will be worn only at night.Measures circumference of both calves at the widest point.Rolls down any excess length at the top of the stocking.