Question

A nurse is caring for a client in an outpatient health clinic.

Answer 1

Correct Answers

Encourage a regular sleep-wake schedule. [ indicated ]
Advise client to notify provider if pregnant. [ indicated ]
Encourage client to sleep until later in the morning. [ not indicated ]
Instruct client to avoid foods that have been fermented or aged. [ not indicated ]
Encourage high-calorie finger foods. [ not indicated ]
Encourage naps during the day when client is tired. [ not indicated ]
Advise client to rise slowly from sitting position. [ indicated ]

Rationale :

Encourage a regular sleep-wake schedule. Indicated

🔷 A regular sleep-wake schedule is indicated because the client is experiencing difficulty sleeping, and consistent sleep habits help improve overall sleep quality.

🔷 Trazodone is often prescribed to promote sleep, but medication works best when combined with healthy sleep hygiene practices.

🔷 Going to bed and waking up at about the same time each day helps regulate the client’s circadian rhythm.

🔷 This intervention can reduce sleep disruption and support better daytime functioning, especially since the client is having trouble focusing on schoolwork.

🔷 Encouraging a structured sleep routine is an appropriate and supportive nursing intervention for this client.

Advise client to notify provider if pregnant. Indicated

🟢 Advising the client to notify the provider if pregnant is indicated because trazodone should be discussed with the provider if pregnancy occurs or is suspected.

🟢 Medication safety is an important teaching point for clients of reproductive age who are starting a new prescription.

🟢 The client is 21 years old, so pregnancy-related teaching is appropriate as part of medication education.

🟢 Prompt provider notification allows the medication regimen to be reviewed for maternal and fetal safety.

🟢 This intervention supports safe medication use and responsible follow-up care.

Advise client to rise slowly from sitting position .Indicated

💎 Advising the client to rise slowly from a sitting position is indicated because trazodone can cause orthostatic hypotension.

💎 Orthostatic hypotension can make the client feel dizzy or lightheaded when standing up too quickly.

💎 Teaching the client to change positions slowly helps reduce the risk of falls or fainting.

💎 This is especially important when starting the medication, because adverse effects may be more noticeable early in therapy.

💎 Safety teaching about position changes is an important part of trazodone education.

Encourage client to sleep until later in the morning. Not Indicated

🟣 Encouraging the client to sleep later in the morning is not indicated because it can disrupt a healthy sleep-wake pattern.

🟣 Oversleeping in the morning may worsen insomnia by interfering with nighttime sleep readiness.

Instruct client to avoid foods that have been fermented or aged. Not Indicated

🟠 Avoiding fermented or aged foods is teaching associated with monoamine oxidase inhibitors (MAOIs), not trazodone.

🟠 Since the client is prescribed trazodone, this dietary restriction is unnecessary and not indicated.

Encourage high-calorie finger foods. Not Indicated

🔴 Encouraging high-calorie finger foods is not indicated because that intervention is more appropriate for a client who is hyperactive or unable to sit still, such as someone in acute mania.

🔴 Although this client has had some weight loss and loss of appetite, there is no evidence that finger foods are specifically needed as the primary nursing intervention here.

Encourage naps during the day when client is tired. Not Indicated

🔵 Encouraging daytime naps is not indicated because naps can make it harder for the client to fall asleep at night.

🔵 Since the client already has difficulty sleeping, promoting daytime naps may worsen the sleep problem rather than improve it.

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Answer 2

Correct Answers

Blank 1 Correct Option: Heart failure
Blank 2 Correct Option: Educate the client about sodium and Obtain a prescription for a diuretic.
Blank 3 Correct Option: Daily weight and Blood pressure.

Rationale :

Condition-Heart failure

🟢 The client’s findings strongly support heart failure because he has bilateral crackles, +3 lower-extremity edema, an S3 heart sound, and an elevated BNP of 350 ng/L.

🟢 BNP is released when the ventricles are stretched from fluid overload, so a value above normal strongly suggests worsening cardiac volume overload.

🟢 The presence of tachycardia, tachypnea, decreased peripheral perfusion, and cool lower extremities further supports impaired cardiac output.

🟢 The combination of pulmonary congestion and peripheral edema is classic for fluid retention related to heart failure.

🟢 This client is most likely experiencing heart failure, not an isolated valvular infection or stenotic disorder.

Actions

Educate the client about sodium

🟢 Teaching the client about sodium restriction is important because excess sodium causes water retention, which worsens edema and pulmonary congestion in heart failure.

🟢 Sodium control is a major nonpharmacologic intervention used to reduce fluid overload and improve symptom management.

🟢 Clients with heart failure need to understand that processed, canned, and restaurant foods are often high in sodium.

🟢 Better sodium control can help decrease the workload on the heart and reduce worsening swelling and shortness of breath.

🟢 This education is an appropriate nursing action for long-term management of heart failure.

Obtain a prescription for a diuretic

🟢 A diuretic is appropriate because this client has clear signs of fluid volume excess, including crackles, edema, and elevated BNP.

🟢 Diuretics help remove excess fluid, which can reduce pulmonary congestion and improve breathing.

🟢 They also decrease peripheral edema and reduce the workload placed on the heart.

🟢 Prompt diuresis is often necessary when a client is showing evidence of worsening heart failure.

🟢 Obtaining a prescription for a diuretic is an important action to address the client’s current status.

Parameters

Daily weight

🟢 Daily weight is one of the most important indicators of fluid status in a client with heart failure.

🟢 Small increases in weight can signal fluid retention even before symptoms become more severe.

🟢 Weighing the client at the same time each day using the same scale improves accuracy and trend monitoring.

🟢 Monitoring weight helps evaluate whether treatment, especially diuretic therapy and sodium restriction, is working effectively.

🟢 This makes daily weight a key parameter to assess progress.

Blood pressure

🟢 Blood pressure should be monitored because it reflects hemodynamic status and helps evaluate how well the client is tolerating treatment for heart failure.

🟢 Diuretics and other heart failure therapies can lower blood pressure, so ongoing assessment is necessary for safety.

🟢 A falling or unstable blood pressure may indicate worsening cardiac output or excessive response to treatment.

🟢 Monitoring blood pressure helps the nurse assess perfusion and overall cardiovascular response over time.

🟢 This makes blood pressure an important parameter in evaluating the client’s progress.

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Answer 3

Correct Answers

Blank 1 Correct Option: arterial obstruction
Blank 2 Correct Option: color and temperature of right lower extremity

Rationale :

Arterial obstruction

🟢The infant is at risk for arterial obstruction because the post-catheterization findings show a weak right pedal pulse, pallor of the right leg, and a cooler right lower extremity compared to the left.

🟢These findings indicate decreased arterial blood flow to the affected leg after a right femoral artery catheterization.

🟢Arterial obstruction is a serious complication of femoral catheterization in infants because the vessel is small and can become compromised by spasm, thrombus, or swelling.

🟢The nurse should recognize that changes in pulse quality, skin color, and limb temperature are classic warning signs of impaired perfusion.

🟢Prompt identification of arterial obstruction is essential to prevent worsening ischemia and tissue injury.

Hypovolemic shock

🟢The infant does not show the strongest evidence of hypovolemic shock, because the dressing has only a quarter-sized amount of dark red blood, and the hematocrit and hemoglobin remain stable.

🟢Although blood pressure is slightly lower, the most concerning and specific finding is impaired perfusion to the right leg, not major blood loss.

Hypoglycemia

🟢The blood glucose of 60 mg/dL is within the stated normal range of 40 to 90 mg/dL for this infant.

🟢 In addition, the infant is receiving dextrose-containing IV fluid, so hypoglycemia is not the priority complication suggested by the assessment findings.

Color and temperature of right lower extremity

🟢 The infant’s right lower extremity is pale and cooler to touch, which are important signs of decreased circulation after femoral artery catheterization.

🟢 After this procedure, the nurse must compare pulses, color, temperature, and capillary refill in both lower extremities to detect vascular compromise early.

🟢 Pallor and coolness are more specific for arterial insufficiency than for bleeding or glucose imbalance.

🟢 The weaker right pedal pulse further supports that blood flow to the limb is impaired.

🟢 These assessment findings explain why the infant is at risk for arterial obstruction.

Blood pressure and right groin dressing drainage

🟢 Blood pressure and catheter-site drainage are important to assess for bleeding, but they do not best explain the most urgent finding in this case.

🟢 The cool, pale leg with weak pulse points more directly to arterial obstruction than to hemorrhagic complications.

Glucose level and type of IV solution

🟢 The glucose level is normal for age based on the reference range provided, and the IV solution contains dextrose, which helps support blood glucose.

🟢 These findings do not explain the vascular changes seen in the infant’s right leg.

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Answer 4

Correct Answers

Blank 1 Correct Option: Reye's syndrome
Blank 2 Correct Option: aspirin administration

Rationale :

Reye's syndrome

🟢Reye's syndrome is the most likely complication because the toddler has a recent viral illness (Influenza A) followed by persistent vomiting, lethargy, and difficulty being aroused.

🟢This condition is strongly associated with giving aspirin to children during or after a viral infection.

🟢Reye's syndrome causes acute swelling in the liver and brain, which can quickly become life-threatening.

🟢The toddler's decreased responsiveness, vomiting, dry mucous membranes, and no voiding suggest worsening systemic illness that requires urgent evaluation.

🟢The combination of influenza infection plus aspirin exposure makes Reye's syndrome the most concerning diagnosis.

Bronchitis

🟢Bronchitis usually presents with cough and airway inflammation, but it does not typically explain lethargy, frequent vomiting, and difficult arousal in this setting.

🟢The toddler's symptoms suggest a more serious systemic complication than a lower respiratory irritation.

Gastroenteritis

🟢Gastroenteritis can cause vomiting and dehydration, but it does not match the classic association of viral illness plus aspirin use.

🟢The change in neurologic status makes Reye's syndrome much more likely than simple gastroenteritis.

Aspirin administration

🟢 Aspirin administration is the key cause because aspirin use in children with viral infections is strongly linked to Reye's syndrome.

🟢 For this reason, aspirin is generally avoided in children unless specifically prescribed for certain conditions.

🟢 The guardians reported alternating aspirin and acetaminophen, which places the toddler at risk.

🟢 Acetaminophen is commonly used for fever in children, but aspirin is the concerning medication in this case.

🟢 The nurse should recognize that the toddler's worsening condition is most likely related to aspirin exposure during influenza.

Oseltamivir administration

🟢 Oseltamivir may cause some gastrointestinal upset, but it is not associated with Reye's syndrome.

🟢 It does not explain the classic pattern of viral illness followed by lethargy and vomiting after aspirin use.

Acetaminophen administration

🟢 Acetaminophen is commonly used as an antipyretic in children and is not the medication classically linked to Reye's syndrome.

🟢 The more dangerous exposure here is aspirin during a viral illness.

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Answer 5

Correct Answers

Vomiting [ appendicitis ; intussusception ]
Abdominal findings [ intussusception ]
Pain rating [ intussusception ]
Stool [ intussusception ]
Temperature [ intussusception ]

Rationale :

Vomiting → Appendicitis and Intussusception

Appendicitis

🔷 Vomiting can occur with appendicitis because inflammation of the appendix commonly causes gastrointestinal upset.

🔷 As appendicitis worsens, nausea and vomiting often follow the onset of abdominal pain.

🔷 This happens because the inflamed appendix irritates the gastrointestinal tract.

🔷 Although vomiting alone does not confirm appendicitis, it is a recognized associated finding.

🔷 For this reason, vomiting is considered consistent with appendicitis.

Intussusception

🔷 Vomiting is also highly consistent with intussusception because bowel telescoping creates an intestinal obstruction.

🔷 Obstruction interferes with normal passage of stomach and intestinal contents, leading to vomiting.

🔷 In children with intussusception, vomiting may begin early and worsen as the obstruction progresses.

🔷 This toddler’s episodic severe pain and abdominal mass make the vomiting especially supportive of intussusception.

🔷 Vomiting is one of the classic manifestations of this disorder.

Abdominal findings → Intussusception

🟢 The abdominal findings are most consistent with intussusception because the child has a distended abdomen, hypoactive bowel sounds, and a small oblong palpable mass in the right upper quadrant.

🟢 A palpable sausage-shaped mass is a classic assessment finding in intussusception.

🟢 The telescoping bowel causes obstruction, which explains the distention and decreased bowel activity.

🟢 Right-sided abdominal tenderness with an upper-right-quadrant mass strongly supports this diagnosis in a toddler.

🟢 These abdominal findings are highly characteristic of intussusception.

Pain rating → Intussusception

🟣 The pain pattern is most consistent with intussusception because the parent reports episodes of severe pain that cause the child to draw the knees to the chest and scream, followed by periods of relative normalcy.

🟣 This intermittent, colicky pain is a hallmark feature of intussusception.

🟣 The pain occurs when the bowel telescopes and then temporarily relaxes between episodes.

🟣 A FLACC pain score of 5 supports that the child is experiencing significant discomfort.

🟣 This type of episodic severe abdominal pain strongly supports intussusception.

Stool → Intussusception

🟠 The stool finding is most consistent with intussusception because the parent reports blood and mucus in the bowel movement.

🟠 This is the classic “currant jelly” stool associated with intussusception.

🟠 The bloody, mucus-filled stool occurs because the telescoped bowel becomes swollen and ischemic.

🟠 This leads to leakage of blood and mucus into the intestinal contents.

🟠 In a toddler with intermittent pain and a palpable abdominal mass, this stool pattern strongly indicates intussusception.

Temperature → Intussusception

🔴 The temperature of 37.4°C (99.3°F) is essentially normal and is more consistent with early intussusception than with infection-driven inflammation.

🔴 Intussusception often presents first with obstruction symptoms such as colicky pain, vomiting, and bloody mucus stool rather than significant fever.

🔴 A normal or only slightly elevated temperature fits the current assessment findings.

🔴 This helps distinguish the condition from illnesses in which fever is a more prominent early feature.

🔴 In this case, the temperature best supports intussusception.

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Answer 6

Correct Answers

Blank 1 Correct Option: Opioid intoxication
Blank 2 Correct Option: Prepare to initiate mechanical ventilation and Obtain a prescription for naloxone.
Blank 3 Correct Option: Pupillary reaction and Respiratory rate.

Rationale :

Condition-Opioid intoxication

🟢The client is most likely experiencing opioid intoxication because the findings include shallow respirations, respiratory rate of 10/min, pupillary constriction, slurred speech, confusion, bradycardia, hypotension, and decreased deep tendon reflexes.

🟢These manifestations are classic for central nervous system and respiratory depression caused by opioid overdose.

🟢The history of chronic back pain, prior oxycodone use, mood changes, housing instability, and unexplained circumstances strongly support possible misuse or overdose of an opioid medication.

🟢Pinpoint pupils together with hypoventilation are especially strong indicators of opioid intoxication.

🟢This client requires urgent treatment because untreated opioid intoxication can rapidly progress to respiratory arrest and death.

Actions

Prepare to initiate mechanical ventilation

🟢 Preparing to initiate mechanical ventilation is appropriate because the client has severe respiratory depression, with a respiratory rate of 10/min and oxygen saturation of 90% on room air.

🟢 Airway and breathing are the immediate priorities in suspected opioid overdose because hypoventilation can quickly lead to hypoxia and respiratory arrest.

🟢 Even when naloxone is given, the nurse must be prepared to support ventilation if the response is delayed or incomplete.

🟢 The client’s shallow breathing, vomiting history, and decreased level of responsiveness also increase the risk for aspiration and airway compromise.

🟢 Respiratory support is a lifesaving action in severe opioid intoxication.

Obtain a prescription for naloxone

🟢Naloxone is the antidote for opioid intoxication and should be obtained immediately when overdose is suspected.

🟢Naloxone works by displacing opioids from receptor sites, which can rapidly improve respiratory depression and level of consciousness.

🟢The client’s pinpoint pupils, bradypnea, hypotension, and altered mental status make naloxone an appropriate and urgent intervention.

🟢Because some opioids outlast naloxone, repeated dosing or continued monitoring may be necessary after administration.

🟢Prompt naloxone treatment can be lifesaving in a client with severe opioid overdose.

Parameters

Pupillary reaction

🟢Pupillary reaction should be monitored because pupillary constriction is a key sign of opioid intoxication, and improvement may indicate a response to treatment.

🟢Opioids commonly cause pinpoint pupils, so serial pupil assessment helps the nurse track neurologic changes.

🟢Worsening or persistent constriction may suggest ongoing opioid effect or inadequate reversal.

🟢Changes in pupil size and responsiveness can provide quick bedside information about the client's progress.

🟢Monitoring pupillary reaction is therefore an important parameter in this overdose situation.

Respiratory rate

🟢Respiratory rate is one of the most critical parameters to monitor because respiratory depression is the most life-threatening feature of opioid intoxication.

🟢The client’s respiratory rate is already 10/min, which indicates dangerously slow breathing.

🟢Improvement in respiratory rate after interventions such as naloxone and ventilatory support is a key sign of stabilization.

🟢Ongoing monitoring helps the nurse recognize recurrent respiratory depression if the opioid effect lasts longer than naloxone.

🟢Careful assessment of respiratory rate is essential to prevent hypoxia and respiratory arrest.

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Answer 7

Correct Answers:

Frequent swallowing

Rationale :

🔷 Frequent swallowing after a tonsillectomy is an important sign of postoperative hemorrhage because the child may be swallowing blood trickling down the throat.

🔷 Children do not always spit out blood, so bleeding can be hidden and recognized only through subtle findings like repeated swallowing.

🔷 The nurse should treat this as a potentially serious complication and inspect for other signs such as tachycardia, pallor, or restlessness.

🔷 Early recognition is critical because hemorrhage after tonsillectomy can progress rapidly and threaten the airway.

🔷 For this reason, frequent swallowing is a classic warning sign that requires immediate attention.

Elevated pain level

🔷 Increased pain can occur after tonsillectomy and does not specifically indicate hemorrhage.

🔷 Bleeding is more strongly suggested by signs such as frequent swallowing or visible blood.

Diminished breath sounds

🔷 Diminished breath sounds may indicate a respiratory issue, but they are not the classic finding of tonsillectomy hemorrhage.

🔷 The more specific early sign is swallowing blood.

Increased drowsiness

🔷 Drowsiness may occur after anesthesia or pain medication and is not the best indicator of bleeding.

🔷 The nurse should prioritize the more specific hemorrhage sign of frequent swallowing.

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Answer 8

Correct Answers:

Suggest the client join a support group for people who have colostomies.

Rationale :

🟢 Suggesting a support group is appropriate because a newly created colostomy often causes body image disturbance, anxiety, and emotional adjustment difficulties.

🟢 Support groups allow the client to meet others who have adapted successfully to life with a colostomy.

🟢 This can reduce isolation, provide realistic encouragement, and help normalize the client’s feelings.

🟢 Refusing to look at the stoma is a common early coping response, and adjustment usually takes time.

🟢 Connecting the client with peer support promotes emotional adaptation and greater readiness for self-care.

Instruct the client's partner to assume care of the colostomy for the client.

🟢 Having the partner take over care may increase the client’s dependence and delay adjustment.

🟢 The goal is to support the client gradually toward acceptance and self-management.

Encourage the client and partner to avoid expressing negative feelings about the colostomy.

🟢 Clients should be allowed to express negative feelings openly as part of healthy adjustment.

🟢 Telling them to avoid those feelings can block coping and make adaptation harder.

Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.

🟢 Transfer to a rehabilitation facility is not necessary solely because the client is struggling emotionally with a new stoma.

🟢 The nurse should first use supportive, therapeutic interventions in the current setting.

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Answer 9

Correct Answers:

Body mass index of 32

Rationale :

🟣 A body mass index of 32 indicates obesity, which is a known risk factor for surgical wound infection.

🟣 Excess adipose tissue has a poorer blood supply, which can reduce oxygenation and delay wound healing.

🟣 Obesity also increases tension on the incision and may create skin folds that trap moisture and bacteria.

🟣 These factors make postoperative wound infection more likely even when other findings are normal.

🟣 For this reason, obesity is the finding that most clearly indicates increased infection risk.

White blood cell count 8,000/mm3 (5,000 to 10,000/mm3)

🟣 A white blood cell count of 8,000/mm3 is within the normal range.

🟣 This finding does not suggest an elevated infection risk by itself.

Blood glucose 90 mg/dL (74 to 106 mg/dL)

🟣 A blood glucose of 90 mg/dL is normal and does not indicate impaired wound healing risk in this context.

🟣 Elevated glucose, not normal glucose, would be more concerning.

Temperature 36.8°C (98.0°F)

🟣 A temperature of 36.8°C is normal and does not suggest infection or added infection risk.

🟣 Fever would be a more concerning assessment finding.

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Answer 10

Correct Answers:

A client who has dementia and is incontinent of urine

Rationale :

🔴 A client who has dementia and urinary incontinence is at the greatest risk for a pressure injury because this client likely has impaired mobility, reduced awareness of discomfort, and constant skin moisture.

🔴 Incontinence exposes the skin to moisture and irritation, which weakens skin integrity and increases breakdown risk.

🔴 Dementia can also reduce the client’s ability to reposition independently or communicate discomfort.

🔴 The combination of cognitive impairment and moisture makes this client especially vulnerable to tissue injury.

🔴 This makes the client with dementia and incontinence the highest-risk choice.

A client who has had a recent myocardial infarction

🔴 A recent myocardial infarction may reduce activity tolerance, but it does not create as many direct skin breakdown risks as dementia with incontinence.

🔴 Pressure injury risk is higher when immobility is combined with moisture and impaired cognition.

A client who has a T-tube following an open cholecystectomy

🔴 A T-tube requires monitoring, but it does not by itself create the highest pressure injury risk.

🔴 The client with dementia and incontinence has more powerful skin breakdown risk factors.

A client who is 2 days postoperative following orthopedic surgery

🔴 A postoperative orthopedic client may have limited mobility, but this client does not necessarily have the added risks of cognitive impairment and incontinence.

🔴 The client with dementia and urine incontinence remains at greater overall risk.

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Nursing Intervention	indicated	not indicated
Encourage a regular sleep-wake schedule.
Advise client to notify provider if pregnant.
Encourage client to sleep until later in the morning.
Instruct client to avoid foods that have been fermented or aged.
Encourage high-calorie finger foods.
Encourage naps during the day when client is tired.
Advise client to rise slowly from sitting position.

Assessment Findings	Crohn's disease	appendicitis	intussusception
Vomiting
Abdominal findings
Pain rating
Stool
Temperature

RN Comprehensive Predictor 2023 (March 2026)

No.

1 :
A nurse is caring for a client in an outpatient health clinic.

Correct Answers

2 :
A nurse on a medical-surgical unit is caring for a middle-aged adult male client.

Correct Answers

3 :
A nurse is caring for a 3-month-old infant.

Correct Answers

4 :
A nurse is caring for a toddler in the outpatient setting.

Correct Answers

5 :
A nurse in an acute care facility is caring for a toddler.

Correct Answers

6 :
A nurse is caring for a client in an emergency department (ED).

Correct Answers

7 :
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

8 :
A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

9 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

10 :
A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

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RN Comprehensive Predictor 2023 (March 2026)

No.

1 : A nurse is caring for a client in an outpatient health clinic.

Correct Answers

2 : A nurse on a medical-surgical unit is caring for a middle-aged adult male client.

Correct Answers

3 : A nurse is caring for a 3-month-old infant.

Correct Answers

4 : A nurse is caring for a toddler in the outpatient setting.

Correct Answers

5 : A nurse in an acute care facility is caring for a toddler.

Correct Answers

6 : A nurse is caring for a client in an emergency department (ED).

Correct Answers

7 : A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

8 : A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

9 : A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

10 : A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

1 :
A nurse is caring for a client in an outpatient health clinic.

2 :
A nurse on a medical-surgical unit is caring for a middle-aged adult male client.

3 :
A nurse is caring for a 3-month-old infant.

4 :
A nurse is caring for a toddler in the outpatient setting.

5 :
A nurse in an acute care facility is caring for a toddler.

6 :
A nurse is caring for a client in an emergency department (ED).

7 :
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

8 :
A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

9 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

10 :
A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?