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A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:

A.

measure intake and output.

B.

check albumin level.

C.

monitor glucose levels.

D.

increase enteral feeding.

Which of the following statements is correct regarding rape?

A.

Most rapes are reported.

B.

Legally, a woman can be raped by her spouse.

C.

Prosecution and conviction for rape is easy.

D.

The most common location of rape is the victim’s own home.

Which of the following is the most appropriate diet for a client who is unable to swallow?

A.

nothing by mouth

B.

nasogastric feedings

C.

clear liquids

D.

total parenteral nutrition

Which of the following statements by a client indicates adequate understanding of preparation for a lipoprotein fractionation test?

A.

“I cannot eat or drink after midnight.”

B.

“I cannot eat for 12 hours before the test.”

C.

“I need to limit my fluid intake.”

D.

“I need to ingest a lipid solution.”

When the nurse is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

A.

corner of the mouth to tragus of the ear

B.

corner of the eye to top of the ear

C.

tip of the chin to the sternum

D.

tip of the nose to the earlobe

Tuberculosis (mycobacterium) usually effects which system?

A.

stomach (GI)

B.

heart (cardiac)

C.

lungs (respiratory)

D.

skin (integumentary)

A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by:

A.

telling his wife to stop cleaning whenever he notices her actions.

B.

making a baseline record of the time the wife spends cleaning.

C.

decreasing the stimuli in the home.

D.

helping his wife with the cleaning.

The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?

A.

pureed canned squash

B.

pureed apples

C.

yogurt

D.

infant rice cereal

The test used to differentiate sickle cell trait from sickle cell disease is:

A.

sickle cell preparation.

B.

peripheral smear.

C.

sickledex.

D.

hemoglobin electrophoresis.

When assessing a client with amytrophic lateral sclerosis (ALS), the nurse should expect which of the following findings?

A.

mental confusion

B.

muscular weakness

C.

sensory loss

D.

emotional liability

A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?

A.

“Because it gives you comfort, you may wear it.”

B.

“It is a violation of religious rights to forbid it.”

C.

“I am sorry, but it is not safe for you to wear the crucifix during this test.”

D.

“You may wear it because it is important to you.”

Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?

A.

Ca

B.

K

C.

Na

D.

Cl

Which of the following is true concerning human immunodeficiency virus (HIV)?

A.

HIV infection involves CD4 receptor protein on the surface of helper T-cells.

B.

The presence of circulating antibodies that neutralize HIV is evidence that the individual has immunity-HIV.

C.

HIV replication occurs extracellularly.

D.

DNA replication

In evaluating the lab work of a client in a hepatic coma, which of the following lab tests is most important?

A.

blood urea nitrogen

B.

serum calcium

C.

serum ammonia

D.

serum creatinine

Jane Love, a 35-year old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?

A.

anemia

B.

edema

C.

painless vaginal bleeding

D.

fatigue