1)Following several episodes of vomiting combined with an increased temperature in a 2-year-old child, the nurse plans to monitor the client for dehydration. Which of the following findings indicate the child is dehydrated?A. Specific gravity of 1.030B. Listless appearanceC. Blood pressure of 80/58D. Depressed fontanel2). A student comes into the college health clinic and describes to the nurse a state of increasing anxiety and the inability to sleep and concentrate. A therapeutic response by the nurse would be:A. “How long has this been going on?”B. “Have you talked to your parents about this yet?”C. “Why do you think you are so anxious?”D. “It sounds like you’re having a difficult time.”3). A nurse is preparing to administer acetaminophen (Tylenol) to a child with a fever. The nurse observes that the client appears small for her age. Which of the following actions should the nurse take?A. Calculate the dosage range based on the child’s weight.B. Administer half of the ordered dose.C. Give the dose as prescribed by the primary care provider.D. Call the primary care provider to verify the dosage.4). A nurse is caring for a post-thoracotomy client who just returned from the operating room period to which postoperative prescription should the nurse give highest priority?A. Administer oxygen via nasal cannula at 6 L/min.B. Monitor urinary output via indwelling urinary catheter every 2 hr.C. Measure cheat tube drainage hourly.D. Maintain Intravenous of D6 1/2 Normal Saline et 125 mL/hr.5). A nurse observes an assistive personnel (AP) taking the call light forcefully from an anxious client and reprimanding the client for using the call light frequently. Which of the following actions should the nurse take first?A. Reassure the client.B. Inform the charge nurse.C. Speak with the AP.D. Document the incident.6)A nurse is caring for a client receiving total parenteral nutrition (TP) therapy via an infusion pump. When collecting data on the client receiving this therapy, which observation by the nurse is of least importance?A. Intravenous siteB. Height of intravenous poleC. Date on tubingD. Contents of solution bag.7). A nurse is planning care for a client hospitalized with an acute exacerbation of systemic lupus erythematosus SLE). Which of the following nursing diagnoses takes the lowest priority?A. Altered body imageB. Activity intoleranceC. Impaired skin integrityD. Impaired physical mobility8). A nurse observes an assistive personnel (AP) taking the call light forcefully from an anxious client and reprimanding the client for using the call light frequently. Which of the following actions should the nurse take first?A. Reassure the client.B. Inform the charge nurse.C. Speak with the AP.D. Document the incident.9)A nurse has applied for a transfer to another unit. When the nurse comes in for an interview, the nurse manager greets the nurse by physically touching the nurse and states that if there were a sexual relationship between them, the nurse’s transfer request would get increased consideration. Which of the following actions should the nurse take?A. Tell the nurse manager in clear terms that this conduct is causing feelings of discomfort and that the behaviors are to stop immediately.B. Put a statement in writing telling the nurse manager that this behavior is unacceptable and keeping a copy.C. Withdraw the request for transfer to the new unit and inform the nursing manager’s superior of the reason.D. Submit a formal written grievance to the nurse manager’s superior detailing the behaviors that the nurse perceives as harassment.
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