1. The nurse is caring for a client on an oncology unit. The client is diagnosed with thrombocytopenia. Which of the following actions is the best way for the nurse to protect the client?

2. The nurse is participating in the care of a 17-year-old male client with a comminuted fracture of the right distal tibia that required surgery. The client returned from surgery four hours ago. The nurse recognizes which of the following as the highest priority when reassessing and documenting postoperative circulation of the casted leg?

3. The nurse is participating in the care of a client diagnosed with left-sided heart failure. While caring for the client, the nurse should monitor which of the following on a daily basis?

4. The nurse is participating in the care of a client who is diagnosed with a panic disorder. The nurse is aware that which of the following physical signs and symptoms may be experienced during a panic attack? Select all that apply.
1. bradycardia
2. delayed speech
3. diarrhea
4. dizziness
5. shortness of breath
6. sweating

5. The nurse is participating in the care of a client with an ostomy. Which of the following suggestions if made by the nurse to the client will be most helpful to control urine leakage when the apparatus is being changed?

6. A client arrives at a physician's office to schedule a series of tests/examinations to rule out prostate cancer. The nurse recognizes that to avoid false test results, the nurse should schedule which of the following diagnostic tests prior to the client receiving a rectal examination?

7. The nurse is participating in the care of a pediatric client with appendicitis. The nurse knows that pain from appendicitis occurs in which part of the abdomen?

8. The nurse is caring for an infant with severe diarrhea. Which of the following room assignments is best for this infant?

9. The nurse is administering Proventil as a metered dose inhalation. The nurse should administer the medication

10. The nurse is preparing to give betamethasone (Celestone) to a pregnant client in preterm labor. The nurse knows that this medication should be administered by which of the following routes?

11. The unit director of a medical surgical floor asks a graduate LPN, 'Based on the HIPAA [Health Insurance Portability and Accountability Act] regulations, what client information is protected and should not be disclosed?' The graduate correctly states which of the following? Select all that apply.
1. client's address
2. client's computer password
3. client's date of birth
4. client's insurance information
5. client's occupation
6. client's medical condition
7. client's social security number

12. The home care nurse is visiting a 72-year-old male client diagnosed with Alzheimer's disease. During the visit, the nurse observes bruising on the client's forearms and legs. The client is also more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation?

13. A nurse is collecting data on a client admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of:

14. The nurse is assisting in the screening of a client for domestic violence. The nurse should utilize which of the following screening tools?

15. The nurse is assigned to care for an adolescent client who overdosed on acetylsalicylic acid (aspirin). The nurse expects to care for a client with which of the following? Select all that apply.
1. jaundice
2. oliguria
3. abdominal pain
4. tinnitus

16. The nurse is caring for a female client 3 days post a total right hip replacement. The client asks the nurse why she must go to a rehabilitation facility. Which of the following is the best response by the nurse?

17. The nurse is caring for a client complaining of pain (7/10 on the pain scale). The nurse will administer the client's prescribed Demerol (meperidine hydrochloride). The client is ordered 50 mg I.M. and the medication is supplied in a 100 mg/mL ampule. What amount should the nurse administer?

18. The nurse is preparing to take a blood pressure (BP) reading on a client. Which of the following actions demonstrate appropriate technique? Select all that apply.
1. centering the bladder of the BP cuff over the brachial artery
2. inflating the BP cuff 30 mm Hg above the reading where the brachial pulse disappears
3. utilizing a BP cuff that is 80% of arm circumference
4. quickly releasing the bulb valve so the pressure drops more than 10 mm Hg per second
5. wrapping the BP cuff so that the lower border is 8 cm above the antecubital space

19. The nurse is participating in the care of a client who states that she is the Tooth Fairy. The nurse should

20. The nurse is assisting in the well-child assessment of a 13-year-old girl. When the child bends over and touches her toes, the nurse observes the following:

The nurse knows that this client should be evaluated for

21. The nurse is assisting in the discharge of a new mother and her newborn. The nurse states that the newborn should travel home from the hospital in the

22. The nurse is assisting in the development of the plan of care for a client experiencing a manic episode. The plan of care should include assessment for which of the following?

23. The nurse is contributing to a staff development program on ostomy care and management. The nurse realizes that additional teaching is not needed when a staff member states that the ostomy pouch should be emptied when it is:

24. The nurse is assisting in gathering data about a client with schizophrenia. The client states that he is 'hearing voices.' Which is the appropriate action by the nurse?

25. The nurse is caring for a client diagnosed with renal failure who requires daily weighings. The nurse directs the nursing assistant (NA) to obtain the client's weight. Which of the following instructions is most important for the nurse to tell the nursing assistant in order for the NA to obtain accurate data?