Question 1

A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother’s discharge teaching plan?

Options :

A : Keep the umbilical area moist with Vaseline until the stump falls off.

B : Keep the umbilical area covered at all times with the diaper.

C : Clean the umbilical cord with alcohol at each diaper change.

D : Clean the umbilical cord daily with soap and water during the bath

Answer: C

Question 2

A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, “Nobody cares about the clients.” The nurse’s most effective response would be:

Options :

A : “How can you say that I don’t care? We just met.”

B : “What makes you think the nurses don’t care?”

C : “You will feel differently about us in a few days.”

D : “You seem angry. Tell me more about how you feel.”

Answer: D

Question 3

Section: Questions Set D

A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing
assessment of arterial blood gases indicate the presence of:

Options :

A : Respiratory alkalosis

B : Respiratory acidosis

C : Metabolic alkalosis

D : Metabolic acidosis

Answer: B

Question 4

A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

Options :

A : Must use the least restrictive measure possible to control the behavior

B : Should put the client in seclusion until he promises to behave appropriately

C : Should apply full restraints until the behavior is under control

D : Should allow other clients to observe the acting out so that they can learn from the experience

Answer: A

Question 5

A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:

Options :

A : Lower lip to the shoulder to the upper sternum

B : Tip of the nose to the lower lip to the umbilicus

C : End of the tube to the first measurement line on the tube

D : Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

Answer: D

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