@ INITIAL EVALUATIVE TEST L M0091. Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 4, 7-day-old fussy infant wit a rectal temperature of 100.6 F (38.1 C) and 6 wet diapers today 2. Client receiving radiation therapy who has 6-in (15.2- cm) arm laceration that is not actively bleeding 3. Client with purulent drainage and crusting of the eyelid with vision unaffected 4, New parent who is crying and overwhelmed, and denies suicidal ideation BCC0092, A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which interventions would the nurse include in the plan of care to prevent wound dehiscence? Select all that apply. Administer docusate orally, daily ‘Administer ondansetron IV PRN for nausea Apply an abdominal binder Implement caloric restriction to promote weight loss 5. Monitor blood sugar to maintain tight glucose control M0001. All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply. 1 Orient the client to the bedside unit and explain the call bell system on admission 2. Place the bedside commode as clase to the bed as possible 3. Remind the client to change position slowly 4, Report observations of changes in client's condition immediately 5. Report whether clients using correct gait and balance while ambulating with walker MHO141. When the community health nurse visits a client at home, the client states, “I haven't slept at all the last couple of nights.” Which response by the nurse illustrates a therapeutic communication response to this client? "Ise." "Really?" "You're having difficulty sleeping?” "Sometimes, | have trouble sleeping too.” LMO014. The nurse caring for a terminally il client asks if the client has an advance directive. The client states, "| already have a power of attorney.” What is the best, response by the nurse? 1. "Apower of attorney (POA) is good to have in place. It sounds like you are on the right track.” 2. “Great. Your POA can start to make decisions for you when you are no longer able to do so.” 3. "Many people find a lawyer at this stage of life, A lawyer can help you get your affairs in order.” 4. "There are many types of POAs. Let's clarify if your POA can make health care decisions for you." BCC0027. A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? Fever Nausea Diaphoresis Abdominal eramps1 2 3 SPOT: @ INITIAL EVALUATIVE TEST LM0022. An emergency department nurse is assigned to triage. Which client should the nurse assess first? Five-year-old with a superficial leg laceration Lethargic 3-month-old with diarthea for the past 12 hours Seven-year-old with a elevated temperature of 104 F (38.3 C) and hematuria Seventeen-year-old with severe, acute abdominal pain 25. A blood transfusion is prescribed for a client with sickle cell exacerbation and a hemoglobin level of 6 g/dL. (60 gIL), Which are appropriate actions by the registered nurse? Select all that apply. Loo: 4, Administer O negative (0-) blood to the AB positive (AB+) client 2, Delegate the fourth set of vital signs to the unlicensed assistive personnel 3, Prime line with normal saline prior to hanging the blood 4, Time the blood infusion to occur over a 6-hour period 5. Validate the client's name and room number with a licensed practical nurse 136. The health care provider gives the preoperative nurse a signed consent form and walks away rapidly. The client turns to the nurse and states, "I don't know what is, going on. Why do I need surgery?" What is the most appropriate action? 1 Call the nursing supervisor Call the operating room scheduler and cancel the surgery Page the health care provider and request clarification on behalf of the client Report the incident to hospital administration BCC0008. The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine, What information will the nurse include in the teaching plan? 1. Adhesive bandaging should remain on the lesions to prevent virus shedding 2. Blood tests will be drawn to ensure the virus is eradioated 3. Condoms should be used during intercourse until the lesions are healed 4, Gloves should be used to apply the medication to the lesions LM0060. A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client, Which of the following is the best action by the nurse? 1. Explain that the client's depression is being treated with medications 2. Explain that the client's depression will not be relieved by aritual 3. Plan a meeting with the health care provider (HCP), family, nurse, and medicine healer to make arrangements for the ceremony 4. Tel the family that such practices are not alowed in the hospital BCC0003. The hospice nurse is assisting a client's family in managing anorexia during end-of-life care. Which interventions would be most supportive? Select al that apply. Administer nausea medication prior to meals Involve the cient in daily meal planning Offer food items the client desires Plan for loved ones to share meal time withthe client 5. Prepare 3 highly nutrtious meals a day on a schedule@ INITIAL EVALUATIVE TEST LM0098. The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine, What action should the nurse take first? 1, Have the unlicensed assistive personnel recheck the client's blood pressure 2. Immediately notify the health care provider 3. Obtain the client's PRN labetalal from the medication dispensing machine 4, Recheck the client's blood pressure with a manual cuff SAF0027. A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery? Hemoglobin 45 g/dL. (150 giL), hematocrit 45% (0.45) International Normalized Ratio (INR) 1.3 Platelet count 296,000/mms3 (295 109/L) Temperature 100.4 F (38 C) with cough SAFO031. Which equipment warnings indicate a clinical issue with a client and not an issue with the programming of the equipment or a mechanical failure? Select all that apply. 1 The glucometer displays "HI" from a blood specimen of a client with diabetic ketoacidosis, 2. The intravenous infusion pump display lights up and sounds an alarm for a few seconds when turned on 3. The patient-contralled analgesia (PCA) pump indicates its unable to read the barcode on the medication vial 4, The pulse oximeter does not register a heart rate pulsation or reading in a client with peripheral vascular disease 5. The ventilator high pressure alarm sounds for a client intubated for acute respiratory distress syndrome ‘SAF0033. The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. WI the best action by the nurse? 1, Instruct the parent to launder the child's clothing and store itin tightly sealed plastic bags 2. Instruct the teacher of the child's classroom to use an insecticide spray 3. Send letters home to all of the children's parents informing them about the finding 4, Send the child home and prohibit school attendance until the infestation has been resolved BCC0030, For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Look at the MAR and chart to note the time of the last dose of analgesic and the client's response. 4. Give the maximum PRN dose within the minimum time frame for relief ‘SAF0034. Which prescriptions for these clients does the nurse question? Select all that apply. 1 Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. — Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4, Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client wth otitis media and penicilin allergy, prescribed ampicilin 500 mg PO@ INITIAL EVALUATIVE TEST SAF0042. The nurse is conducting intake interviews at the clinic, Which client situations would require the nurse to intervene? Select all that apply. 4. Client with ron deficiency anemia takes iron supplements with milk 2. Client takes levothyroxine early in the morning on an empty stomach 3. Client taking phenazopyridine for urine infection states that the urine has turned orange 4, Client taking metronidazole mentions going to a wine- tasting party tonight 5. Client with closed-angle glaucoma takes over-the- counter diphenhydramine for a cold LM0103. The nurse is working on a busy medical-surgical unit and is responding to the client cal lights. Which statement would be the priority to assess first? 1. 65-year-old female client recently started on celecoxib says, "| am having some nausea and my upper back and shoulder are hurting quite abit" [51%] 2. Aclients child says, "My parent has been here for 2 days without anything to eat or drink." 3. Aparaplegic clent with mute stage 4 pressure ulcers says, "| have had a bowel movement and need to be cleaned up.” 4. A postoperative client says, "| am very nauseous and just threw up. This pain medicine is making me really siok." ‘SAFO067. The nurse is reinforcing teaching to the parent of a child diagnosed with ringworm. Which statement by the parent indicates a need for further teaching? 4, "Antifungal cream must be applied to all affected areas to eradicate ringworm from the body.” 2, "Hand washing is very important as ringworm can be spread among humans and pets." 3, "My child has been infected by a worn and must be treated to ridit from the body.” 4. "My child will be uncomfortable due to itching, but this is not a dangerous condition.” LM0042. After receiving the shift report, the nurse should assess which infant first? 1. An infant bom 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min 2. Aninfant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dl. (2.2 mmol/L) 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago 4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C) P0199. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscuttating lung sounds 2. Obtaining the client's temperature 3. _ Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease 00003. Which statements made by a group of community clients communicate to the nurse a potential warning sign of cancer? Select all that apply. 1, “Forthe past 2 years, | have had a chronic productive cough for 3 months out ofthe year.” 2, “I.seem to have heartburn an hour ater | eat eggs and ‘sausage and drink whole milk.”@ INITIAL EVALUATIVE TEST 3. "Last month when | was doing my self-breast examination, | noticed a lump the size of a marble.” 4, "My moles itchy and the borders have become uneven with a blackish to bluish color.” 5. "Recently | have noticed that my bowel movements appear black.” IMMU0011. A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago. The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should be delayed? Select all that apply. Haemophilus influenzae type b (Hib) Hepatitis B (Hep 8) Measles, mumps, rubella (MMR) Pneumococcal conjugate (PCV) Varicella iMMU0016. Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination? 1. Haemophilus influenzae type b vaccine for client allergic to penicilin 2. Hepatitis A vaccine fora client with a “cold” and temperature of 99.0 F (37.2 C) 3. Pneumococcal vaccine for client with local swelling after last immunization 4, Varicella-zoster vaccine for client recently diagnosed with leukemia (GD0024, The registered nurse has completed a well-baby assessment of an 18-month-old. Which assessment findings prompted the nurse to make a referral for a formal developmental screening test? 4. Cannot climb steps by self, pulls a toy, tums the pages of a book 2. Is botlle fed, can hold a spoon, creeps down stairs 3. Throws a ball, is able to point to 2 or 3 body parts, cannot draw a picture 4, Uses 2 words, cannot hold a cup, can seat self in a small chair LM0012. The charge nurse on the telemetry unit is making client assignments, Which client is appropriate to assign to the licensed practical nurse (LPN)? 1. Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void 2. Client being discharged after deep vein thrombosis who needs teaching on how to setf-administer ‘enoxaparin injections 3. Client who has just been admitted tothe telemetry unit from the emergency department with a rule-out myocardial infarction 4, Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg GD0042. The nurse assesses 4 infants. Which assessment finding would require follow-up by the health care provider? 1. 3-week-old whose anterior fontanelle bulges with crying 2, 4-week-old whose posterior fontanelle is soft 3. 6-month-old with birth weight of 7 Ib 3 oz (3.3 kg) who now weighs 12 Ib (5.4 kg) 4, 12-month-old with birth weight of 6 lb 4 oz (2.8 kg) who now weighs 20 lb (9.1 kg)@ INITIAL EVALUATIVE TEST MHO070. The nurse is conducting a follow-up interview with a client who is being treated for depression and Suicidal ideation. Which factor best indicates the client is not currently at risk for suicide? 1. Client claims to have more energy and vigor since starting therapy 2. Client has clear future plans involving personal goals and family milestones 3. Client has signed a contract promising not to commit suicide 4. Client reports losing amitiptyiine and requests a refill ‘SAFO061. A client is being admitted to the health care facility with a new diagnosis of Clostridium difficile colitis Which elements of infectious disease precautions are necessary when providing routine care for this client? Select all that apply. 1. Alcohol-based sanitizers for hand cleaning 2, Client in single-room (private) isolation 3. Nurse using N96 respirator 4, Nurse using sterile gloves, 5, Nurse using surgical mask 6, Nurse wearing disposable gown MHOO71. The mental health nurse engaged in dialogue with a client would recognize transference when the client makes which statement? 1. "Ican pretend to have feelings; how would you know the difference?” 2. "My roommate doesn't seem to like me very much.” 3. "Sharing my thoughts with you will be difficult; you remind me of my sister.” 4, "The people who work here do not seem genuine.” LM0025. The nurse completes the following drug administrations. Which would require an incident report? 1 2. CV0157. The nurse is prey Client with chronic stable angina and blood pressure ‘of 84/52 mm Hg; isosorbide mononitrate held Client with depression stopped phenelzine yesterday; escitalopram given today Client with diabetes and morning glucose of 90 mg/dL (5.0 mmol/L); the daily NPH insulin 20 units given at 8:00 AM Ciient with pulmonary embolism and Intemational Normalized Ratio (INR) of 2.5; warfarin given ing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? Select all that apply. Blood pressure Blood urea nitrogen Liver enzymes Potassium White blood cell count MHO078. A client with schizophrenia that is resistant to other antipsychotic medications is about to start on a course of clozapine. Which of these periodic measurements has the highest priority in this client? 1 2 ‘Complete blood count (CBC) and absolute neutrophil count (ANC) Electrocardiogram Fasting blood sugar and fasting lipids Height, weight, and waist circumference €C0008, To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the airJilled interface of the stopcock at the phlebostatic axis. Where is it located? 1 ‘Angle of Louis at 2nd intercostal space (ICS) to left of stemal border@ INITIAL EVALUATIVE TEST 2. Aortic area at 2nd ICS to right of sternal border 3, Level of atria at 4th ICS, % anterior-posterior (AP) diameter 4. 5th ICS at mid clavicular ine (MCL) MH0098. The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on.” What is the best priority response by the nurse? 4. "Do you have any frends in the building?* 2, "Have you had any thoughts of hurting yourself?” 3. "Tell me more about how you'e feeling" 4, "You'te not thinking of killing yourself, are you?" MHO160, The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 41, “Ino longer feel that I deserve the beatings my husband inflicts on me." 2. “My attendance at the meetings has helped me to see that | provoke my husband's violence." 3. “Tenjoy attending the meetings because they get me cut ofthe house and away from my husband.” 4. ‘Ican tolerate my husband's destructive behaviors now that | know they are common with alcoholics." ‘SP0053. A student nurse has prepared instructions for the caregiver of an 8-month-old who weighs 16.5 lb. The health care provider (HCP) has prescribed oral amoxicillin 25 mg/kgiday in 2 divided doses for 5 days as treatment for acute otitis media. Amoxicillin for oral suspension comes packaged as 125 mgJ5 mL. Which instruction by the student nurse needs an intervention by the RN? 4. "Give the medicine right before feeding your baby.” 2. "Give your baby 7.5 mL of the medicine at 8 AM and 8 PM." 3. “Give your baby the medicine for the full days even if the baby seems better before then.” 4, “Stroke your baby's cheek gently before administering the medicine.” P0134. The health care provider prescribes a continuous IV insulin infusion for a client. The insulin drip is initiated with 50 units of regular insulin in 100 mL of normal saline solution at §units/hr. At what rate in mililiters per hour does the nurse set the IV pump? Record your answer using a whole number. Answer: (muh) CV0130. A client with heart failure is started on furosemide, The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Na= 139 meq K =5.1 meqil Ca=8 megl Mg = 0.8 meqi Altial fibrilation Atrial flutter Mobitz II Torsades de pointes CV0147. A client is admitted to the cardiac care unit with atrial fibrillation. Vital signs are shown in the exhibit. Which prescription should the nurse perform first? Click on the exhibit button for additional information. 1. Administer diltiazem 20 mg IVP 2. Administer rivaroxaban 20 mg PO 3. Draw blood for a thyroid function test@ INITIAL EVALUATIVE TEST 4, Send the client for echocardiogram MHOO74, The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? 1. "Ineed for you to get rid of these bugs that are crawling under my skin.” 2, "Hear that? She told me to kill my father. 3. "That song is a message sent to me in secret code.” 4, "Those Martians are trying to poison me with the tap water." CV0162. A nurse is caring for a 6-year-old who had a cardiac catheterization. During assessment of the groin ;, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the child's leg. What should the nurse's first action be? 1. Apply a new pressure dressing to the catheterization site 2. Call the health care provider (HCP) 3. Check the peripheral pulse distal to the catheterization site 4, Remove the dressing and apply direct pressure above the puncture site M0097. An unaccompanied 16-year-old girl comes to the ‘emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? 1. Administer care unt the parents or guardians can be reached 2. ‘Admit the client but without giving care until the parents or guardians can be reached 3. Perform a pregnancy test to see if the client qualifies as an emancipated minor 4. Provide health care and follow-up advice but do not, give any direct care CV0196. A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80 mm Hg 2. Heart rate 100/min 3. Serum creatinine 2.5 mg/dL (221 umolL) 4, Serum potassium 3,5 mEqiL (3.5 mmol/L) C0010. A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15cm H20 (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP? Barotrauma Decreased oxygen saturation Hypertension Oxygen toxicity G10053. The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority? Contact the health care provider Cut the tube with scissors Increase gastric suction evel Place the client in high Fowler position1 2 END0042. The nurse evaluates the effectiveness of @ INITIAL EVALUATIVE TEST C0057. Which client incident would be classified as an adverse event that requires an incidentleventiirregular ‘occurrencelvariance report? Select all that apply. Client admitted with white blood cell count of 28,000 mmm (28.0 x 109/L) and dies from sepsis Client receives 1 mg morphine instead of prescribed 0.5 mg morphine Client refuses pneumonia vaccination and contracts pneumonia Nurse did not report client's new hemoglobin result of 6 g/dL (60 gIL) to oncoming nurse Provider was not notified of client's positive blood culture results desmopressin use for diabetes insipidus in a client with a pituitary tumor, Which client assessment finding indicates that the medication is having the desired effect? Appetite has improved Blood glucose is 110 mg/dl. (6.1 mmol/L) Urine output has decreased Urine specific gravity is lower CV0167. A clientis admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 20!mi . The nurse has received an order to adr ter adenosine 6 mg IV. Which action should the nurse take? 1 2 ‘Adenosine is contraindicated for SVT. Verity the order with the health care provider ‘Administer medication only through a central venous access Administer medication rapidly over 1-2 seconds followed by a saline flush Mix medication in 50 mL normal saline and administer over 10 minutes ENDO155. The community health nurse visits a client at home, Prednisone, 10 mg orally daily, has been prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary? 1, “can take aspirin or my antihistamine if | need it.” 2, *Ineed to take the medication every day at the same time.” 3. “Ineed to avoid coffee, tea, cola, and chocolate in my diet” 4, “If {gain more than 5 pounds a week, I will call my health care provider (HCP).” 10432. You are caring for a client with peptic ulcer disease, Which assessment finding is the most serious? Projectile vomiting Burning sensation 2 hours after eating Coffee-ground emesis Boardlke abdomen with shoulder pain ENDO156. A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this medication? Select all that apply. Administer methimazole with food, Place the client on a low-calorie, low-protein diet. Assess the client for unexplained bruising or bleeding. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches. 5. Use special radioactive precautions when handling the client’ urine forthe first 24 hours following inital administration. ‘AP0031, The nurse is counseling a pregnant client who is HIV positive. Which information is appropriate to discuss?@ INITIAL EVALUATIVE TEST 1. Infant should be exclusively breastfed for 6 months to receive maternal antibodies 2. Infant wil not require treatment for HIV after birth 3. Prescribed antiretroviral therapy should be continued during pregnancy 4, Tetanus-diphthera-pertussis vaccine should be avoided until after birth C0204. A client is diagnosed with lower-extremity deep venous thrombosis (DVT) after a cross-country road trip. Which clinical manifestations most characteristic of a DVT does the nurse expect to assess? Select all that apply. Blue, cyanotic toes Calf pain Dry, shiny, hairless skin Edema Warmth and erythema ‘SP0094. The orthopedic health care provider instructs a client with a fractured right femur, who has been non- weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? 4. 2-point gait 2. 3-point gait 3, 4-point gait 4. S-point gait RES0085, The nurse is teaching a 9-year-old child with asthma how to use a metered-dose inhaler (MDI). Place the instructions in the appropriate order. All options must be used. 4. Exhale completely 2. Deliver one puff of medication into spacer 3. Place lips ightly around the mouth piece 4, Rinse mouth with water 5, Shake MDI and attach it to spacer 6. Take a slow deep breath and hold for 10 seconds MH0003. The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol Which assessment findings does the nurse expect to find? Select all that apply. Absent deep tendon reflexes Cold, clammy skin Muscle rigidity Restlessness and agitation Sinus tachycardia 10080, The school nurse is teaching a class of 10-year- old children about prevention of dental caries. Which recommendations would be part of the nurse's teaching plan? Select all that apply. 4. Chewing sugar-free gum 2, Including milk, yogurt, and cheese in the diet 3. Minimizing intake of sweet, sticky foods 4, Rinsing the mouth with water after meals when brushing is not possible 5, Substituting fut juices and drinks for sugary, carbonated beverages €C0048. Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had. surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately? 1. Difficult to arouse 2, Muscle stiness 3. Pinpoint pupils, 4. Temperature 94 F (34.4 C)@ INITIAL EVALUATIVE TEST \VA0046. The nurse is reviewing the laboratory results for 610042. The nurse teaches a client diagnosed with iron- a child scheduled for tonsillectomy. The nurse determines deficiency anemia about iron-rich foods. Which meal that which laboratory value is most significant to review? does the client choose to indicate that teaching has been effective? 4. Creatinine level 2. Prothrombin ime 1. Chicken salad with lettuce on French bread, 3. Sedimentation rate chocolate pudding, and milk 4, Blood urea nitrogen level 2. Fatfree yogurt, carrot sticks, apple slices, and diet soda 3. Ham, steamed carrots, green beans, gelatin dessert, 10129. A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a and iced tea Kale salad with boiled eggs and dried fruit, a brownie, and orange juice central ine at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour, What is the most appropriate nursing action? €C0029. Two days after surgical debridement for a pressure ulcer, the client develops new-onset confusion, a temperature of 101 F (38.3 C), blood pressure 74/48 mm Hg, pulse 110/min, respirations 26imin, and oxygen saturation 88% on room air. Place the prescribed interventions in the order the nurse would perform them. All options must be used. 1, Hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mLihr for 1 hour 2, Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr 3, Hang dextran in saline until the new bag arrives, then resume TPN at 75 mUhr 4, Hang lactated Ringer's unti the new bag arrives, then resume TPN at 75 mL/hr ‘Administer acetaminophen every 6 hours as needed Administer oxygen using a non-rebreathing mask ‘Assess lung sounds Increase 0.9% IV normal saline rate from 75 mL/hr to 200 mLihr Reassess a ful set of vital signs INT0059. A client is brought to the emergency department with partial thickness burns to his faci neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. ‘SAF0144. A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is. having frequent watery stools. Which action will you take first? Restrict fluids Assess for airway patency. Administer oxygen as prescribed. Place a cooling blanket on the client Elevate extremities if no fractures are present. Prepare to give oral pain medication as prescribed, 1 Notify the physician about the loose stools 2, Obtain stool specimens for culture. 3, Instruct the client about correct hand washing 4, Place the client on contact precautions.@ INITIAL EVALUATIVE TEST (C0056. The nurse is caring for an 11-month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? Select all that apply. New-onset right-sided paralysis of extremities Pulse rate sustained at 120/min Respirations continued at 38/min Sudden inabilty to be aroused to an awake state Temperature of 101.3 F (38.5 C) Gl0101. The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply. Albumin ‘Ammonia Bilirubin Prothrombin time Sodium €C0064. The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate? 1. Assess the insertion site for presence of subcutaneous emphysema 2. Notify he surgeon of a large airleak 3, Take no action as the chest tube is functioning appropriately 4, Tum down the wall suction unti the bubbling disappears NEU0037. The nurse taught the caregiver of a child a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP). The caregiver shows understanding of the instructions by contacting the HCP about which symptom? 1. A temperature of 99 F (37 C) that occurs during the evening 2. The child cannot recall tems eaten for lunch the previous day 3. The child vomits after awakening from a nap and 1 hour later 4, The VP shunt s palpated along the posterior-ateral portion of the skull SAF0037, A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound, Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply, 1. Open asterile container of 4 x 4's using the outermost, corner to peel back the cover 2. Pull glove off over the soiled dressing to encase it before disposal 3. Save unused sterile 4 x 4's by taping original package shut for the next dressing change 4, Wash hands prior to putting on gloves and after removing them 5. Wrap soiled dressing in paper towels before disposing of it in the trash can NEU0043. The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response? Consumes 600 mL liquid over 4 hours Insertion site dressing saturated with clear fluid Observed lying inthe right sided Sims position Reports a headache rated 6/10@ INITIAL EVALUATIVE TEST LM0008. There has been a community disaster with multiple victims, Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply. 1. Acute head injury with Glasgow Coma Scale of 12 2. Admitted with cihosis of iver with oozing esophageal varices 3. Asthma exacerbation with peak flow at 85% of personal best 4, Deep venous thrombosis on IV heparin with platelets 40,000/mm3 (40 x 109/L) 5. Myasthenia gravis with ptosis in the evening CC0012. The nurse provides triage to victims of a mass casualty event on arrival in the emergency department. Which victim would need to be seen first? Client with a broken neck and agonal breaths Client with a head injury and fixed pupils, Client with an open right femur fracture Client with shallow lacerations over legs and arms