Comp 2

stages of labor

1st: dilating stage 3 phases: Latent (0-3cm) Active (4-7cm) Traditional (8-10cm w/ urge to push) 2nd stage: delivery 3rd: placental delivery 4th: recovery- primary goal to prevent hemorrhage from uterine atony, 1st void within 1 hour and then q2-3 hrs, Rhogam

The primary health care provider (HCP) orders 1,000 mL of Ringer's lactate intravenously over an 8-hour period for a 29-year-old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute? Record your answer as a whole number.

25

A nurse in a diabetes clinic receives phone calls from four clients with type 1 diabetes. Which client's call would be the highest priority for the nurse to return?

A client reporting "I noticed that my urine has a foul odor."

A nurse practicing in a nurse-managed clinic suspects that an 8-year-old child's chronic sinusitis and upper respiratory tract infections may result from allergies. She orders an immunoglobulin assay. Which immunoglobulin would the nurse expect to find elevated?

Immunoglobulin E

A high-risk adolescent is given a tuberculin intradermal skin test to detect tuberculosis infection. How long after the test is administered should the results be evaluated?

In 48 to 72 hours

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentatio

It provides quick access to abnormal findings.

A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first?

Place the client on her left side

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

Placing the client in respiratory isolation

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?

Posterior tibial

A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy?

Support from her partner

After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?

The client has developed tolerance to the dose of morphine.

A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. What should the nurse determine is the most likely cause of the client's constipation?

The client is experiencing an adverse effect of the aluminum hydroxide.

Levothyroxine adverse effects

Tremors, headache, nervousness, palpitations, tachycardia, allergic skin reactions, loss of hair in the first few months of therapy in children, diarrhea, nausea, vomiting

Which family should the nurse determine as most in need of follow-up?

a single parent with a toddler who has third-degree burns over 20% of the body

A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection (UTI) and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which recommendation to the client's health care provider (HCP)? a prescription to place the client in restraints a reevaluation of the client's mental status a transfer of the client to a medical unit a transfer of the client to a nursing home

a transfer of the client to a medical unit

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:

enhances protein synthesis.

A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of:

esophagitis

tracheostomy tube

indwelling tube inserted directly into the trachea to assist with ventilation

radiation enteritis

inflammation of intestinal tissue caused by radiation therapy

esophagitis

inflammation of the lining of the esophagus

tardive dyskinesia

involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotic drugs that target certain dopamine receptors

A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report which adverse effect?

irregular heartbeat

A nurse is caring for a client in the 13th week of pregnancy who develops hyperemesis gravidarum. The nurse is reviewing the client's laboratory report. Which finding indicates the need for intervention?

ketones in urine

After a right total knee replacement, the client's right leg is placed in a continuous passive motion (CPM) machine. Nursing responsibilities when caring for a client with this apparatus should include:

maintaining proper positioning of the leg on the CPM machine.

The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which support?

praise and encouragement

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The expected outcome of applying pressure is that the pressure:

prevents the medication from entering the tear duct.

hiatal hernia

protrusion of a part of the stomach upward through the opening in the diaphragm

The nurse is planning to assist the health care provider (HCP) with a thoracentesis for a client who has a pleural effusion. Which position would be appropriate for the client to assume?

sitting upright and leaning on an overbed table

subcutaneous injection:

the administration of medication by injection into the fatty layer just below the skin; 45-90 degrees

Femur

thigh bone of the leg; the longest and strongest bone in the body

To prevent recurrence of cystitis, the nurse should plan to encourage the female client to include which measure in her daily routine?

wearing cotton underpants

The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which indications of infection should the nurse detect during this stage?

whitish yellow patches in the mouth

Which statement by the client with rheumatoid arthritis would indicate the need for additional teaching to safely receive the maximum benefit of aspirin therapy? "I always take aspirin with food to protect my stomach." "Once I learned to take my aspirin with meals, I was able to start using the inexpensive generic brand." "I always watch for bleeding gums or blood in my stool." "I try to take aspirin only on days when the pain seems particularly bad."

"I try to take aspirin only on days when the pain seems particularly bad."

A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which question would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped?

"What are you thinking about before you start to prepare supper?"

The health care provider orders 2 g of ampicillin in 50 ml of D5W, to infuse IV piggyback (IVPB) over 30 minutes, for a client who had a right total knee replacement secondary to osteoarthritis. At what rate would the nurse set the IV infusion pump in milliliters per hour? Record your answer using a whole number.

100

A nurse is preparing to administer beractant to a preterm infant. The order is for 4 ml/kg. The neonate weighs 2,000 g. How many total milliliters will be used for one dose? Record your answer as a whole number.

2 kg in 2000 g. So 8!

The nurse is caring for an alert 2-month-old child and assesses a sunken fontanelle. Which action would be most appropriate for the nurse to take based on the assessment?

Monitor fluid intake and output.

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.

Pepperoni pizza Bacon Cheese Soft drinks

breath sounds: bronchial, tracheal, vesicular, and bronchovesicular...

Question!

A client experiencing alcohol withdrawal tells the nurse that she is upset about going through detoxification. Which goal is the priority for this client?

Working with the nurse to remain safe

A child is receiving peritoneal dialysis to treat renal failure. To detect early signs of peritonitis, the nurse should stay alert for:

abdominal tenderness

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?

amount of subcutaneous tissue

After teaching a child with leukemia about a scheduled bone marrow aspiration, the nurse determines that the teaching has been successful when the child identifies which place as the site for the aspiration?

back of the hipbone

Propranolol (Inderal)

beta-blocker used to treat high blood pressure, irregular heartbeats, shaking (tremors), and other conditions

Beta blocker adverse effects

bradycardia, hypotension. av block, heart failure, dizziness, fatigue, hyper/hypoglycemia, hyperlipidemia, wheezing, impotence, dyspnea

A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first:

call the poison control center.

In the immediate period following application of a plaster cast to correct a child's congenital clubfoot, the nurse should:

change the child's position at least every 2 hours.

adverse effects aluminum hydroxide:

constipation; loss of appetite

The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use?

light stroking of the skin surface

Risk of metoclopromide:

Tardive dyskinesia; longer you take it higher the risk

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent:

"Does your child tug at either ear?"

An older adult who experienced a brief delirium realizes that the condition was caused by prescription medication intoxication. Which of the following statements indicates the need for further education?

"I get medicines from three different doctors and they don't all know what I'm taking."

A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?

"Take a warm tub bath or shower before exercising. This may help with your discomfort."

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma.

Tibia

shin bone

A healthy client presents to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound?

vesicular

A client has been admitted to the hospital for treatment of kidney stones. The client is allowed a regular diet and is reviewing the menu. The client asks the nurse where the Atkins diet items are on the menu. What is the nurse's understanding of the diagnosis and diet?

A diet high in protein may strain the kidney function.

The nurse receives a physician's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31

A 10-year-old child has blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?

50 mg/dL (2.8 mmol/L)

IM injections

90 degree angle

Which situation demonstrates correct principles of confidentiality?

An emergency department nurse reports suspected child abuse.

Nurses' observance of professional rituals helps standardize practice and ensure efficiency. Which of the following is a characteristic of rituals?

Common and observable expressions of culture.

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Document presenting signs and symptoms. Compare ABG findings with previous results. Maintain intake and output records.

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?

Elevate the affected part

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet.

A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should:

increase the client's fluid intake to 3,000 mL/day.

stomatitis

inflammation of the mucosa of the mouth

A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take?

Report the situation to the nursing supervisor.

Pressure Ulcer Stages:

Stage 1: non-blanchable redness Stage 2: partial thickness loss Stage 3: full thickness loss, w/o undermining, see fat Stage 4: 3+ undermining, see tendon, muscle

When administering metoclopromide for vomiting related to migraine headaches, the nurse notices that the client has continuous movements of tongue and lip smacking after taking this medication. The nurse should

Stop the medication and notify the health care provider.

Nortriptyline (Pamelor)

TCA

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions?

The seal around the stoma is intact.

When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse should assess for:

diaphoresis

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

dislodge the autografts.

When assessing an older adult as a candidate for crutch walking, the nurse should take into account that for some elderly people, crutch walking is an impractical goal primarily because of decreased:

motor coordination.

A nurse receives a report that a client has had an overdose of heparin. Which of the following actions by the nurse is most important in managing the overdose?

obtain an order to give protamine sulfate

Charting by exception

shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes

Upon the child's return from the postanesthesia recovery unit (PACU) after a tonsillectomy, the nurse should place the child in which position?

side lying

A client has extreme fatigue and is malnourished, and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food low in which nutrients?

vitamins B6 and B12, folate, iron, and copper

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?

Assessing present voiding patterns

The home health nurse is assessing a client and determines that she has an unsteady gait. The client tells the nurse that she has a history of falls. Which nursing action represents an advocacy role for the home health nurse?

Contacting a health care equipment resource to rent a walker for the client to use

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

The client rinses around the clean incision site, using gauze squares moistened with normal saline.

vesicular breath sounds

Normal breath sounds made by air moving in and out of the alveoli. Question... what are bronchial breath sounds...

The nurse brings the infant to the new mother after obtaining assessment data and performing newborn interventions. Which of the following behaviors exhibited by the mother demonstrates that effective bonding is beginning to take place?

The mother looks at the newborn with direct eye contact.

Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma. How will the nurse determine that the client has been applying the skin barrier correctly?

There is no skin irritation around the stoma.

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?

Use a pulse oximeter to determine oxygen saturation.

Metaprotenerol

bronchodilator

A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include:

chemotherapy exposure and risk factors.

The nurse is conducting an initial nursing history of a client who is experiencing pain related to bone cancer. The most important information to gather in this initial assessment is the:

client's self-reporting of the pain experience.

The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids?

decreased ability to detect thirst

The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the health care provider (HCP) when the client has:

decreased breath sounds

effleuage

message technique of light & deep stroking w/ heels & palms of hands

Atkins Diet

High protein, low carbs

Which of the following statements indicates that a client understands discharge instructions about propranolol?

"I will assess my heart rate before I take my medication."

Reasons for a tracheostomy:

to bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth to reach the lungs); to clean and remove secretions from the airway; prolonged mechanical ventilation (breathing machine); and to more easily, and usually more safely, deliver oxygen to the lungs.

A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care?

Assisting the client with bathing and dressing by giving clear, simple directions

A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F (39.5° C) rectally. What is the most appropriate initial nursing intervention?

Give acetaminophen

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?

Health habits, family relationships, affect, and thought patterns

An adult male client has been unable to void for the past 12 hours. What is the best method for the nurse to use when assessing for bladder distention in a male client?

Palpate for a rounded swelling above the pubis.

A client has been diagnosed with hypothyroidism and started on synthetic levothyroxine for thyroid replacement therapy. Which of the following is the most important effect to report to the physician?

Palpitations and chest pain on exertion

The nurse and occupational therapist are planning an outdoor volleyball game and picnic for eight mental health clients. What action should the nurse take for the two clients taking nortriptyline for depression?

Provide protective clothing and apply sunscreen before going out

The nurse is caring for a client who has been admitted for inpatient psychiatric treatment after being diagnosed with somatic symptom disorder. When planning the client's care, it will be important for the nurse to consider which aspect of treatment?

Providing instruction and assessment for stress management techniques

Metoclopromide (Reglan)

Reglan (metoclopramide) is a dopamine antagonist that is used as an antiemetic (anti-vomiting) agent used to treat nausea, vomiting, loss of appetite, heartburn and early satiety (feeling of fullness). First developed as an antipsychotic in the 1960s, today it is mostly used to treat nausea, vomiting, heartburn, and similar conditions.

A client who was recently discharged from the psychiatric unit telephones the unit to speak to the nurse. The client states that she took her children to the neighbors' house and has turned on the gas to kill herself. She is home alone and gives the nurse her address. Which action should the nurse take next?

Tell the caller that another nurse will telephone the police.

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?

Test all stools for occult blood.

An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do?

Verify that the site, side, and level are marked.

continuous passive motion machine

Your healthcare provider prescribed a continuous passive motion (CPM) machine to use after surgery. The CPM machine is attached to a knee or other limb on which the surgery was performed. While you relax, the machine constantly moves the knee or other limb through a range of motion for a period of time. CPM is thought to prevent joint stiffness, relieve pain, and regain normal motion. The CPM has supportive padding, a power supply, and a frame that adjusts to your body.

A new mother asks the maternity nurse about sudden infant death syndrome (SIDS). The nurse tells the mother that SIDS most likely to occur at what age?

1 week to 1 year, peaking at 2 to 4 months

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priory intervention?

Ask for additional information from the client.

The nurse is providing nutrition counseling for an obese adolescent. What is the most effective way for the nurse to obtain a nutrition history from this client?

Ask her what she ate yesterday if it was a typical day.

The nurse is caring for a client with unsuccessful laboring who is anticipating a caesarian section. What is the final assessment the nurse should make in the birthing room immediately before the client is transported to the operating room?

Fetal heart tones

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate?

low-protein, low-sodium, low-potassium

A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to evaluate:

maternal vital signs and fetal heart rate (FHR).

A client is in the manic phase of bipolar disorder. To help the client maintain adequate nutrition, the nurse should plan to:

offer finger foods and sandwiches.