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A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?

A.

increased platelet count

B.

increased fibrinogen

C.

decreased fibrin split products

D.

decreased bleeding

Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as:

A.

mild.

B.

moderate.

C.

severe.

D.

panic.

Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)?

A.

lettuce

B.

eggs

C.

chocolate

D.

butterscotch

Which sign might the nurse see in a client with a high ammonia level?

A.

coma

B.

edema

C.

hypoxia

D.

polyuria

Which is the proper hand position for performing chest percussion?

A.

cup the hands

B.

use the side of the hands

C.

flatten the hands

D.

spread the fingers of both hands

A woman asks, “How much alcohol can I safely drink while pregnant?” The nurse’s best response is:

A.

“The amount of alcohol that is safe during pregnancy is unknown.”

B.

“Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.”

C.

“Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.”

D.

“You can have a drink to help you relax and get to sleep at night.”

The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?

A.

Use the defrost setting on microwave ovensto warm bottles.

B.

When refrigerating formula, don’t feed the baby partially used bottles after 24 hours.

C.

When using formula concentrate, mix two parts water and one part concentrate.

D.

If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it.

A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:

A.

is pregnant.

B.

is immunocompromised.

C.

is allergic to neomycin.

D.

has a cold.

A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, “There must be some mistake in the diagnosis.” The nurse determines that the client is demonstrating which of the following?

A.

denial

B.

anger

C.

bargaining

D.

acceptance

Signs of impaired breathing in infants and children include all of the following except:

A.

nasal flaring.

B.

grunting.

C.

seesaw breathing.

D.

quivering lips.

A client recently lost a child due to poisoning. The client tells the nurse, “I don’t want to make any new friends right now.” This is an example of which of the following indicators of stress?

A.

emotional behavioral indicator

B.

spiritual indicator

C.

sociocultural indicator

D.

intellectual indicator

Rehabilitation services begin:

A.

when the client enters the health care system.

B.

after the client requests rehabilitation services.

C.

after the client’s physical condition stabilizes.

D.

when the client is discharged from the hospital.

Legal protection of confidentiality:

A.

extends only to written documentation.

B.

extends to the electronic dissemination of information not identifiable to a specific client.

C.

is important only within the court system.

D.

extends to both written and verbal information.

The nurse should teach parents of small children that the most common type of first-degree burn is:

A.

scalding from hot bath water or spills.

B.

contact with hot surfaces such as stoves and fireplaces.

C.

contact with flammable liquids or gases resulting in flash burns.

D.

sunburn from lack of protection and overexposure.

Someone who has received a recent tattoo should be screened for:

A.

tuberculosis.

B.

herpes.

C.

hepatitis.

D.

syphilis.