Question 1

To which of the following assessment data should the nurse give highest priority for a client admitted to the emergency room in a hepatic coma?

Volume A

Options :

A : Neurological status

B : Airway adequacy

C : Ammonia levels

D : Gastrointestinal bleeding

Answer: B

Question 2

A woman is seen in the physician's office because of nutritional anemia. During a nursing history, the client makes all of the following comments. Which comment would be indicative of nutritional anemia?

Volume D

Options :

A : "I get a headache about twice a week."

B : "I have trouble sleeping at night."

C : "I get pain in my lower back."

D : "I always feel tired and weak."

Answer: D

Question 3

When maintaining accurate records in situations of suspected abuse, the nurse should document

Volume A

Options :

A : an interpretation of the client-s statements regarding the abuse.

B : a body map to indicate size, color, areas and types of injuries.

C : a description of the suspected abuser.

D : generalized statements about the events leading up to the abuse.

Answer: B

Question 4

Which of the following nursing interventions would be most important for determining fluid balance in a client with end-stage renal failure?

Volume A

Options :

A : Monitor urine specific gravity

B : Measure fluid intake and output

C : Weigh daily

D : Record frequency of bowel movements

Answer: C

Question 5

A nurse in the prenatal clinic has a nutritional conference with a primigravida who is ten weeks pregnant.

Which of these comments, if made by the woman, would be an accurate statement about nutritional needs?

Volume C

Options :

A : "Since I don't like to drink milk, I've been using it in my cooking and eating extra cheese."

B : "I'm being careful with my weight. I'll be sure to gain no more than sixteen pounds with the pregnancy."

C : "I'll be using a salt substitute instead of salt throughout my pregnancy."

D : "If I take multivitamins, then it will be all right for me to continue to omit my lunch."

Answer: A

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