1. A nurse in an emergency department completes an assessment on an adolescent
client that has conduct disorder. The client threatened suicide to the teacher. Which if
the following statements should the nurse include in the assessment?
a. Tell me about your siblings
b. tell me what kind of music you like
c. tell me how often you drink
d. tell me about your school schedule
2. A nurse is observing bonding with the client and her newborn. Which of the following
actions by the client requires the nurse to intervene?
a. holding the newborn in an enface position
b. asking the father to change the newborns diaper
c. requesting the nurse take the newborn to the nursey so she can rest
d. viewing the newborns actions to be uncooperative
3. The nurse is caring for a client who is taking levothyroxine. Which of the following
findings should indicate that the medication is effective?
a. weight loss
b. decreased BP
c. absence of seizures
d. decrease inflammation
4. A nurse is planning discharge teaching for cord care for the parent of a newborn.
Which instructions would you include in the teaching?
a. Contact provider if the cord turns black
b. clean the base of the cord with hydrogen peroxide daily
c. keep the cord dry until it falls off
d. the cord stump will fall off in 5 days
5. A nurse is assessing a client in the PACU. Which of the following findings indicates
decreased cardiac output?
a. shivering
b. oliguria
c. bradypnea
d. constricted pupils
6. A nurse is assisting with mass casualty triage explosion at a local factory. Which of
the following client should the nurse identify as the priority?
a. client with massive head trauma
b. client with full thickness burns
c. client with indications of hypovolemic shock
d. client with open fracture
7. A nurse is receiving 4 patients. Which of the following clients should the nurse assess
first?
a. a client who has ileal conduit and mucus in the pouch
b. client AV has additional vibration palpated
c. client who has chronic kidney disease with cloudy dialysate outflow
d. a client with TURP has red tinged urine in bag
8. A nurse is caring for a client who just received the first dose of lisinopril. The following
is an appropriate nursing intervention?
a. place cardiac monitoring
b. monitor clients oxygen saturation
c. provide standby assist with the client from bed
d. encourage foods high in potassium
9. A nurse is caring for a client who is in labor and is receiving electronic fetal
monitoring. The nurse is reviewing the monitor tracing and notes early decelerations.
Which of the following should the nurse expect?
a. fetal hypoxia
b. abrupto placentae
c. post maturity
d. head compression
10. A nurse is caring for a client who has chronic kidney disease. The nurse should
identify which of the following laboratory values as an indication for hemodialysis?
a. glomerular filtration rate of 14mL/min
b. BUN 16
c. serum mag 1.8
d. serum phosphorus 4
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