CAPSTONE FINAL EXAM
The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention would be included to prevent renal failure for this client?
Encouraging fluid intake
A female client with acquired immunodeficiency syndrome (AIDS) is receiving treatment with zidovudine and has blood drawn for analysis. The nurse reviews the laboratory results (see image). Which laboratory values should the nurse relay to the healthcare provider?
Hemoglobin and White blood cells
The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reduce the swelling, the nurse would perform which action:
apply a ice pack to the area
The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action would be monitor which clinical parameter?
blood glucose
The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation?
dry skin and neck sore throat redness around the neck
The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing preciotous labor Which is the nurses priority nursing action?
keep the client in a side lying position
A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?
my baby will need antibacterial medication for 8 weeks
The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication?
neck stiffness
The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that It has drop To decrease the Incidence or supine hypotension, the nurse would encourage the client to remain in which position?
side-lying
A client delivers a viable neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse recognizes that this score is based on which factors?
skin color muscle tone respiratory effort
The client develops thrombophlebitis after a cesarean section, and the nurse instructs the client on appropriate activities. which client would indicate a need for more education?
the client who ambulates in the hall frequently
the nurse is assisting with caring for a client who is receiving cisplatin. which adverse effects are associated with this medication?
tinnitus ototoxicity hypocalcemia nephrotoxicity
The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a pletelet count of 10,000 mm.? Which nursing intervention would be incorporated into the plan of care?
use toothbrush with soft bristles
A client asks the nurse Why her newborn babv needs an injection of vitamin K (phytonadione). The nurse would make which statement to the client?
"This injection prevents your baby from abnormal bleeding
A child is diagnosed with infectious mononucleosis. The nurse reinforces home care instructions to the parents about the care of the child. Which statement by the parents would indicate a need for further education?
"We should maintain the child on bed rest for 2 weeks."
The nurse conducts discharge teaching with the parent of a 3-year old child with pertussis. Which recommendation should the nurse include in the teaching?
"Reduce environmental triggers such as smoke, dust, and strong odors."
The healthcare provider writes an order for Nystatin Oral Suspension 250,000 units by mouth every 6 hours for oral thrush. The pharmacy dispenses 500.000 units/3mL per dose. The nurse will administer?
1.5
A client is receiving a Heparin IV infusion at 22 mLs/hour. The Heparin mixture is 250 mg in 500 mLs D5W. The nurse recognizes that the client is receiving?
11
The healthcare provider orders a continuous IV infusion of insulin at 9 units per hour. Insulin is mixed at the strength of 75 units in 100mL 0.9% sodium chloride. The nurse will set the infusion rate?
12
the nurse reinforces instructions to the parents of a child with lukemia regarding monitoring for infection. which statement by the parents indicates the need for further teaching?
I need to take my child's rectal temperature daily
a client with chronic kidney disease?....
A) hemocrat
The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which parent statement would indicate a need for further education?
A. "I will make sure that my child does not drink too much fluids."
The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer?
A. Increased appetite B. Difficulty swallowing D. Elevated prostate-specific antigen levels
The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). What is the most likely reason for this finding?
Another infection caused by the leukopenic effects of the medication
A client in labor experiences sudden difficulty breathing and chest pain. The healthcare provider suspects an mniotic fluid embolism. Which nursing intervention is most appropriate for this client?
Apply oxygen 8-10L/min by face mask
the client with ovarian cancer is being treating with ?
B) extremely
Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
BUN 26 mg/dL
The nurse is preparing to care for a newborn who is receiving phototherapv. Which measures would be implemented?
Cover the newborn's eyes with shields Reposition the newborn every 2 hours
the nurse is providing discharge instructions to the parents of a 16-year-old who is undergoing treatment for Hodgkin's disease. which statement by the parents indicates a need for further teaching?
D) I will recommend that my child use a......
A licensed practical nurse (LPN) is assisting in the care of a client who is receiving oxytocin to induce labor. The LPN plans notify the registered nurse immediately if which symptom is noted?
Decreased blood pressure, increased pulse
A new mother brings her 1-month old infant to the clinic for a checkup. Which immunization would the nurse recommend to the child at this age?
HepB
The nurse is assisting in caring for a pregnant client who is receiving intravenous magnesium sulfate for the management of preeclampsia and notes that the client's deep tendon reflexes are absent. Which physician's order would the nurse question?
Increase the rate of magnesium sultate Inrusion
An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?
Iron-deficiency anemia
The client needs to receive a unit of blood in 3 hours. The unit of blood contains 320 mLs. The nurse sets the infusion rate at 85 mLs/hour. What will be the outcome of using this infusion rate?
It will take more than 3 hours to infuse the blood
the nurse cares for a client who has an allergy to latex. which nursing interventions are appropriate when caring for this client?
Keep a latex-free supply cart available for the client's care Use medications from glass ampules
The healthcare provider writes an order for Theodur Elixir 200 mg by mouth every 8 hours. The pharmacy dispenses 100ma/10mL. The nurse administers 30 mLs. Is this the correct dose?
No: this dose Is too large
The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?
Notify the heath care provider
The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes variable decelerations of fetal heart rate (FHR) on the monitor strip. What are the immediate nursing actions?
Reposition the mother Give the mother supplemental oxygen check the mothers vital signs
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome. Which additional sign is consistent with fetal alcohol syndrome?
Respiratory distress
A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence?
Retained Dlacental fragments Maternal vaginal infections
The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted?
Serum Amylase
The nurse cares for a child who is suspected of scarlet fever. Which symptom would support the diagnosis of scarlet fever?
Skin rash that blanches with pressure
the nurse would monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?
Tachypnea and retractions
The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. which data, if noted in the infant, indicate the criterion for early discharge has not been met?
The infant has not passed urine or stool
The nurse is caring for the client diagnosed with a skin infection who is prescribed amoxicillin 500 mg every 8 hours. Which sign/symptom would indicate to the nurse that the client is experiencing a frequent side effect related to the medication?
Vaginal itching and discharge
the nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions would be included on the list?
Wear a supportve. non-underwire bra. Continue to breast-feed if the breasts are not too sore Maintain a fluid intake of at least 3 Liters daily take the full course of prescribed antibiotics
