2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? Place the newborn 45 cm (18 in) from the light source 3 an assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60 5 A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first? Arrange a meeting with teenage mothers who are high school students in the community 6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first? Place an NPO sign on the door of a client scheduled surgery 7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nursing actions is appropriate? Covering insertion site with a transparent dressing 8 A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care? A client who has agonal respirations 9 A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? Series of four hepatitis vaccines is recommended to prevent viral hepatitis 10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the following actions by nurse demarcates veracity? The nurse explains the potential risks of treatment 11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the client’s wishes. The nurse committed which of the following? Battery 12 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure? Bilateral lung crackles