The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting? A. Spinal flexibility B. Leg length disparity C. Hypostatic blood pressure D. Scoliosis Correct Answer: D. Scoliosis A check for scoliosis,… Read More »
A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? A. Slow pulse rate B. Weight gain C. Decreased systolic pressure D. Irregular WBC lab values Correct Answer: B. Weight gain… Read More »
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action? A. Check vital signs. B. Massage the fundus. C. Offer a bedpan. D. Check for perineal lacerations. … Read More »
What is the most common symptom in a client with abdominal aortic aneurysm? A. Abdominal pain B. Diaphoresis C. Headache D. Upper back pain Correct Answer: A. Abdominal pain Abdominal pain in a client with an abdominal aortic aneurysm results from the disruption of normal circulation in the abdominal… Read More »
Johnny, a firefighter, was involved in extinguishing a house fire and is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Atelectasis C. Bronchitis … Read More »
A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient? A. Change the disposable mask immediately after use. B. Change gloves immediately after use. C. Minimize patient contact. D. Minimize conversation with the patient. … Read More »
Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate? A. Urine output greater than 30ml/hr B. Respiratory rate of 21 breaths/minute C. Diastolic blood pressure greater than 90 mmHg D. Systolic blood pressure greater than 110 mmHg Correct… Read More »
A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome? A. Simian crease B. Brachycephaly C. Oily skin D. Hypotonicity Correct Answer: C. Oily… Read More »
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A. Unequal leg length B. Limited adduction C. Diminished femoral pulses D. Symmetrical gluteal folds Correct Answer: A. Unequal leg length Shortening of a leg is a sign of… Read More »
Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? A. Abdominal pain B. Absent pedal pulses C. Angina D. Lower back pain Correct Answer: D. Lower back pain Lower back pain results from the expansion of an aneurysm. The… Read More »