2. The client takes heparin 12, 000 units daily by subcutaneous injection. Today’s aPTT level is 45 seconds. Which action does the nurse take first?
3. The client is the single parent of the 2 week old baby, the firstborn child. The client had considered terminating the pregnancy but continued the pregnancy. There is little client family support. The client has a history of an editing disorder. The nurse knows which nursing diagnosis is most important for the client?
4.A nurse provides care for the newborn in the delivery area. The baby is breathing and crying well with good color. The nurse knows which priority is next?
5. The nurse care for the adolescent diagnosed with acquired aplastic anemia. The diagnosis is related to the practice of huffing substances with benzene. Which goal is the most important for this client during immunosuppression?
6. The nurse is preparing to insert an indwelling urinary catheter. Prioritize the order of steps..
From start to finish. All options must be used.
7.The nurse assesses the position of the fetus at the beginning of labor. The nurse feels the fetal occiput toward the left side of the pregnant clients sacrum. How does the nurse interpret thus finding?
8. A client diagnosed with infective endocarditis is discharged home on IV antibiotic therapy. The nurse knows the client understands the discharge treatment plan when the client makes which statement?
9. The client sustained a right hip fracture. The client had surgery to repair the hip. The nurse prepares for the client to return from surgery to the surgical unit. Which equipment is out important for the nurse to have available?
10. The nurse care for the 4 year old child. The parents report the child is irritable and has lost weight. The nurse assesses the child and discovers an irregular heart rate at 18- beats per minute and rest at 24 per min. Which does the nurse do first?
11. The nurse care for a client with as kin rash. The client scratches the rash and the skin starts to bleed. The nurse includes which nursing diagnosis in the clients plan of care?
12. A nurse in the clinic performs a pregnancy test and tells the couple they are pregnant. They are both excited and appear happy. At the next clinic visit, the client tells the nurse the partner is quiet and withdrawn although seeming initially happy at the news. Which is the best response by the nurse?
13. The Hospitalized client is scheduled for a paracentesis because of ascites. The nurse identifies which client goal related to the procedure?
14. A client reports indigestion that is not relieved with antacids. The client appears pale and ashen and the skin is cool and clammy. Which additional assessment data does the anticipate? (Select all that apply)
15. A client is 30 weeks pregnant. The delivery will be by cessarean birth due to a breech presentation. Which information does the nurse give the client regarding the delivery? (Select all that apply)
16. The nurse obtains a specimen for arterial blood gasses from a client. Which principles guides the nurse?
17. The client takes rifampin and isoniazid for turberculosis. The nurse knows the client understands the teaching about rifampin when which client statement is made?
18. A parent brings an infant client to the emergency department after the infant fell out of the high chair. The nurse assess the infant for a head injury. Which assessment data indicates the infant needs further testing? (select all that apply)
19. A psychiatrist nurse cares several clients with personally disorders. The nurse recognizes that clients diagnosed with narcissistic personality disorder exhibit which characteristic? (Select all that apply.)
20. The nurse presents a Program on Lyme disease. The nurse determines teaching is needed when a child makes which statement?
21. A client diagnosed with psoriasis is treated with etanercept. The nurse knows the client understands the disease and treatment when the client makes which statement.
22. The Nurse cares for the 13 year old child diagnosed with vesicoureteral reflux secondary to strictures caused by repeated bladder infections. The child receives continuous low dose antibiotics. The nurse assesses the compliance of treatment. Which questions does the nurse ask the child?
(Select all that apply)
23. A client had a myocardial infarction. The nurse teaches the client to seek immediate treatment for which symptoms? (select all that apply)
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