After the nurse observes an absent patellar reflex, a decrease in the respirations, and a decrease in the urine output,

what would be the priority nursing care for an obstetrical client who is receiving magnesium sulfate for pre-eclampsia? a. Administer calcium gluconate. b. Evaluate the magnesium level. c. Implement respiratory resuscitation. d. Administer Narcan.

During the hospital delivery of a neonate, which intervention would be a priority? a. Provide the mother with emotional support. b. Maintain the mothers comfort. c. Prepare the sterile field. d. Monitor the fetal heart rate.

Before performing CPR, the initial assessment would be the: a. cause of the arrest. b. unresponsiveness of the client. c. age of the client. d. presence of the brachial pulse.

At birth a newborn delivered by C-section is depressed and at 1 minute has not begun spontaneous respirations due to copious secretions. The priority nursing intervention would be to: a. intubate the newborn. b. initiate CPR. c. administer naloxone (Narcan). d. suction the airway.

Before beginning oxygen on a client with COPD, it is important to confirm an oxygen flow rate of: a. 2 liters per minute. b. 5 liters per minute. c. 6 liters per minute. d. 9 liters per minute.

Which parameter most affects the accuracy of a measurement made on a pulse oximeter? a. Hypothermia. b. Irritability. c. Food intake. d. Hand used.

After evaluating the circulation in an arm in a cast, which assessment requires physician notification? a. Apical pulse of 88. b. Tingling, cold fingers. c. Lack of cooperativeness by the client. d. Warm fingers with an alteration in capillary refill.

The nurse has administered sublingual nitroglycerin to a client complaining of chest pain. Which observation is most important for the nurse to report to the next shift? a. The client indicates a need to urinate frequently. b. Blood pressure has decreased from 140/80 to 90/70. c. Respiratory rate has increased from 16 to 20. d. The client indicates the chest pain has subsided.

After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing as fast drip. He receives 850 cc in less than 60 minutes. Which observation would indicate a problem? a. CVP reading of 12 b. Hypotension. c. Oliguria. d. Rales and tachycardia.

A client develops acute renal failure and is on continuous peritoneal dialysis. Which assessment finding would indicate the most common complication associated with this procedure? a. Hypotension b. Hypertension. c. Pruritis. d. Bradycardia.

Which reflex would be abnormal to observe in a 6-month-old child? a. Presence of a positive Babinski reflex. b. Extrusion reflex occurs when feeding. c. Able to voluntarily grasp objects. d. Rolls from abdomen to back at will.

A client is admitted to the emergency room with a gunshot wound in the chest and in severe respiratory distress. Which nursing action has the highest priority when managing this emergency case? a. Establish and maintain a patent airway. b. Start cardiopulmonary resuscitation. c. Initiate oxygen therapy. d. Obtain an arterial blood gas.

ALL assessment would document hemolytic transfusion reaction except: a. Hypotension. b. Chills. c. Urticaria d. Lower back discomfort.

The nurse would anticipate which medication would be ordered to reduce the extrapyramidal side effects commonly associated with chlorpromazine hydrochloride (Thorazine)? a. Chlordiazepoxide (Librium). b. Benzatropine mesylate (Cogentin). c. Amitriptyline hydrochloride (Elavil). d. Methylphenidate hydrochloride (Ritalin).

The nurse would administer AquaMephyton (Vitamin K.) to a neonate by: a. an injection into the vastus lateralis. b. mixing it in the formula. c. drops into the inner canthus. d. subcutaneously into the anterior thigh.

During chemotherapy of an outpatient who is lethargic, weak, and pale, which intervention would be most important for the nurse to implement? a. Establish emotional support. b. Position for physical comfort. c. Maintain enteric isolation. d. Hand washing prior to care

Which response to mannitol is desired for decreasing the intracranial pressure of a client with a closed head injury? a. The blood pressure increases to 150/90. b. Urinary output increases to 175 cc/hour. c. Decrease in the level of activity. d. Absence of fine tremors of the fingers.

A 28-year-old client, gravida 2, para 1, in her third trimester of pregnancy has had diabetes since age 12. Which statement made by the client indicates an understanding regarding the insulin requirements during the third trimester? a. "I cannot continue to exercise as this will increase my insulin needs." b. "I understand my insulin requirements will increase as my pregnancy progresses." c. "Since the baby has a normal pancreas, my insulin needs will not change." d. "The more weight I gain, the more insulin I will need to take."

A client is in labor and is receiving magnesium sulfate IV. Which assessment is most important to report to the nurse on the next shift? a. Respiratory rate change from 13/min. to 15/min. b. Increase in anxiety and hyperactivity. c. Presence of nausea and refusal to take clear liquids. d. Urine output change from 40 cc/hr to 20 cc/hr.

The nurse is caring for a client who vigorously follows several rituals daily, including frequent hand-washing. The clients hands are now reddened and sensitive to touch. Which nursing action would be least helpful initially? a. Provide special skin care b. Give positive reinforcement for non-ritualistic behavior. c. Limit the amount of time the client may use to wash hands. d. Protect the client from ridicule by other clients on the unit.