2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy.

Which of the following interventions should the nurse include?

Place the newborn 45 cm (18 in) from the light source

3 an assistive personnel tells the nurse that several client measurements were obtained with morning

vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60

5 A community health nurse recognizes that the teen pregnancy rate in the community has increased.

Which of the following program-planning strategies should the nurse implement first?

Arrange a meeting with teenage mothers who are high school students in the community

6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the

assistive personnel, which of the following task does the nurse direct the AP to complete first?

Place an NPO sign on the door of a client scheduled surgery

7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the

following nursing actions is appropriate?

Covering insertion site with a transparent dressing

8 A nurse is performing disaster triage following a natural disaster. Which of the following should the

nurse identify as the highest priority to receive care?

A client who has agonal respirations

9 A nurse is planning to provide community education about viral hepatitis. Which of the following

should the nurse plan to include in the teaching?

Series of four hepatitis vaccines is recommended to prevent viral hepatitis

10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the

following actions by nurse demarcates veracity?

The nurse explains the potential risks of treatment

11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last

time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the

client’s wishes. The nurse committed which of the following?

Battery

12 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI).

Which of the following assessment findings should the nurse report to the provider as a possible

indication of left-sided heart failure?

Bilateral lung crackles

13////

14 A nurse is caring for a group of clients. The nurse should request a referral for a speech language

pathologist for which of the following clients? 

A client who has difficulty swallowing

15 A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has

major depressive disorder. Which of the following should the nurse include in the teaching?

A general anesthetic is administered prior to ECT treatments

16 A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess

the newborn for which of the following manifestations of neonatal abstinence syndrome

Tachypnea/irritability/tremors

17 A nurse is caring for a client following an open colectomy. Which of the following findings places the

client at risk for delayed wound healing?

Hyperemesis

18 A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit.

The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has

selected. Which of the following actions is appropriate for nurse to take?

Ask the charge nurse to assign an experienced nurse to act as a resource

19 A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total

body radiation and intense chemotherapy. The client’s sibling comes visit but has obvious manifestations

of an upper respiratory infection. Which of the following nursing actions is appropriate at this time?

Allow the sibling to wave at the client through the window or door

20 A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central

venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer’s lactate at 150

mL per hr. prior to starting the infusion, which of the following actions should the nurse take?

Review the chest x-ray report