A nurse is completing an admission assessment on an adolescent who is vegetarian.

He eats milk products but does not like beans. Which of the following items should the

nurse suggest to order for lunch to provide nutrients most likely to be lacking in his diet?

- Peanut butter and jelly sandwich

A nurse is performing a pre-college assessment on an adolescent. Which of the

following immunization should the nurse anticipate administering? - Meningococcal

polysaccharide vaccine

A nurse is a assessing a client who has left-sided heart failure. Which of the following

findings should the nurse expect? - Dependent edema

A nurse is caring for a client who has active TB and is to be started on IV rifampin

therapy. The nurse should instruct the client that this medication can cause what

adverse effects? - Body secretions turning a red-orange color

A nurse is caring for an infant who has pyloric stenosis. Which of the following

manifestations should the nurse expect? - Projectile vomiting

A nurse receives a call from a parent of a child who has Von Willebrand disease and is

having a nosebleed. Which of the following instructions should the nurse give the

parents? - Hace the child sit with his head tilted forward and hold pressure on nose for

10 min

A nurse is assessing a child who has sickle cell anemia. Which of the following findings

should the nurse expect? - Pain

A nurse is proceeding preop teaching by demonstrating breathing to a client who is

scheduled for surgery in the morning. Which of the following actions should the nurse

include in the demonstration - Place both hands on the side of her rib cage

A nurse is assessing a 3yr old who has aortic stenosis. Which of the following findings

should the nurse expect - Murmur

Weak pulse

Hypertension

Chest pain

A nurse is planning care for a client who has idiopathic thrombocytopenia purpur. Which

of the following manifestations is the most appropriate for the nurse to monitor? - Fever