Page 2579 - Saunders Comprehensive Review For NCLEX-RN

therapy.”
4. “The primary health care provider would prefer that you discuss
treatment options with the oncologist.”
901. An infant born with an imperforate anus returns from surgery after requiring
a colostomy. The nurse assesses the stoma and notes that it is red and
edematous. Based on this finding, which action should the nurse take?
1. Elevate the buttocks.
2. Document the findings.
3. Apply ice immediately.
4. Call the primary health care provider.
902. The nurse is performing an initial assessment on a newborn infant. When
assessing the infant’s head, the nurse notes that the ears are low-set. Which
nursing action is most appropriate?
1. Document the findings.
2. Arrange for hearing testing.
3. Notify the pediatrician.
4. Cover the ears with gauze pads.
903. The clinic nurse is assessing jaundice in a child with hepatitis. Which
anatomical area would provide the best data regarding the presence of
jaundice?
1. The nail beds
2. The skin in the sacral area
3. The skin in the abdominal area
4. The membranes in the ear canal
904. The nurse is assigned to care for a client in traction. The nurse creates a plan
of care for the client and should include which action in the plan?
1. Ensure that the knots are at the pulleys.
2. Check the weights to ensure that they are off of the floor.
3. Ensure that the head of the bed is kept at a 45- to 90-degree angle.
4. Monitor the weights to ensure that they are resting on a firm
surface.
905. The nurse is setting up the physical environment for an interview with a
client and plans to obtain subjective data regarding the client’s health. Which
interventions are appropriate? Select all that apply.
1. Set the room temperature at a comfortable level.

2. Remove distracting objects from the interviewing area.

3. Place a chair for the client across from the nurse’s desk.

4. Ensure comfortable seating at eye level for the client and
nurse.
5. Provide seating for the client so that the client faces a strong

light.
6. Ensure that the distance between the client and nurse is at
least 7 feet (2.1 meters).
906. The nurse is caring for an older adult who has been placed in Buck’s

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