6. The nurse is caring for a client who reports vomiting for the last week. Which of the following findings would be a priority for the nurse to report to the primary health care provider?
A. Client has no appetite.
B. Dizziness upon standing
C. Urine output of 20 mL/hr
D. Temperature of 100.2 F (37.9 C)
7. The nurse is caring for a client who sustained burn injuries to the neck, chest, and around the entire left leg. The nurse observes the client is restless, has a hoarse voice, and has decreased pedal pulses in the left foot. Which of the following actions should the nurse take first?
A. Provide a dose of fentanyl 25 mg via IV push.
B. Prepare the client for an escharotomy of the left leg.
C. Start an IV bolus of warmed lactated Ringer’s solution.
D. Administer high-flow oxygen via a non-rebreather mask.
8. The nurse is administering a vaccine to an 18-month-old child. Which of the following statements by the nurse demonstrates appropriate communication with a toddler-aged client?
A. “We are all done! Would you like a yellow or orange bandage?”
B. “Don’t cry! I promise that this won’t hurt at all. It is just a little poke.”
C. “I am going to use an antibacterial wipe to kill all of the bacteria on your skin!”
D. “Imagine you’re an astronaut getting a special shot to help you on your space mission!”
9. The nurse is caring for a 17-year-old client who was brought to the emergency department by his mother after sustaining head and neck trauma. Which of the following actions should the nurse take first?
A. Immobilize the cervical spine.
B. Provide supplemental oxygen.
C. Obtain a thorough history of injury.
D. Complete a neurological assessment.
10. The nurse is educating a client with insomnia about the importance of sleep hygiene. Which client statements indicate that the teaching was effective? Select all that apply.
A. “I shouldn’t lift weights late in the evening.”
B. “A light snack before bed is okay if I’m feeling hungry.”
C. “When I read at night, I should sit in my chair and not in my bed.”
D. “I can take diphenhydramine every night to ensure quality sleep.”
E. “I should go to bed by 9 p.m. and lay there to help make myself sleepy.”