A client has cancer of the liver. The nurse should be most concerned about which nursing diagnosis?

The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client’s most appropriate priority nursing diagnosis?

The home health nurse is visiting a 15-year-old with sickle cell disease. Which information obtained on the visit would cause the most concern? The client:

The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?

The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse’s initial action should be to:

The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?

A client being treated with sodium warfarin has an INR of 8.0. Which intervention would be most important to include in the nursing care plan?

Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?

The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?

The nurse is caring for a 12-year-old client with appendicitis. The client’s mother is a Jehovah’s Witness and refuses to sign the blood permit. What nursing action is most appropriate?

A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?

The nurse is evaluating nutritional outcomes for an elderly client with anorexia nervosa. Which data best indicates that the plan of care is effective?

The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?

The client is having a cardiac catheterization. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best?

Which action by the healthcare worker indicates a need for further teaching?

The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?

The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

The registered nurse is making assignments for the day. Which client should not be assigned to the pregnant nurse?

Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?

The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:

Which assignment should not be performed by the registered nurse?

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Which nurse should be assigned to care for the postpartal client with preeclampsia?

Which medication is used to treat iron toxicity?

The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:

The home health nurse is planning for the day’s visits. Which client should be seen first?

The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?

To assist with the prevention of urinary tract infections, the teenage girl should be taught to:

A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

Which instruction should be given to the client who is fitted for a behindthe-ear hearing aid?

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?

The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?

A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?

The client is admitted to the unit. A vaginal exam reveals that she is 3cm dilated. Which of the following statements would the nurse expect her to make?

The client is having fetal heart rates of 100–110 beats per minute during the contractions. The first action the nurse should take is to:

In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:

A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?

The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:

The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent phase of labor?

As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?

The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

Which of the following is a characteristic of a reassuring fetal heart rate pattern?

The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is: