Final exam
41.A nurse is caring for a newborn who is formula fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 at 1830. How many mL of formula should should the nurse record as the clients intake for the shift? (Answer) 90mL Correct Rationale: Add the total ounces: 0.5 + 1 + 0.5 + 0.5 + 0.5 = 3 oz. Then multiply the total ounces by 30 mL: 3 x 30 = 90 mL InCorrect Rationale: Add the total ounces: 0.5 + 1 + 0.5 + 0.5 + 0.5 = 3 oz. Then multiply the total ounces by 30 mL: 3 x 30 = 90 mL
(Answer) 90mL Correct Rationale: Add the total ounces: 0.5 + 1 + 0.5 + 0.5 + 0.5 = 3 oz. Then multiply the total ounces by 30 mL: 3 x 30 = 90 mL InCorrect Rationale: Add the total ounces: 0.5 + 1 + 0.5 + 0.5 + 0.5 = 3 oz. Then multiply the total ounces by 30 mL: 3 x 30 = 90 mL
4. A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record? (Answer) A. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only." Rationale: This statement presents data and nursing observations in a factual, non-judgmental manner about this incident. The nurse should also include vital signs, any additional findings, notification of the provider, treatments or procedures the provider prescribes, and the client's response. B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime. Rationale: This statement is judgmental and places blame on the assistive personnel. C. Client fell out of bed and cut his forehead due to sedative-induced confusion. Rationale: This statement includes an imprecise description of the client's injury and also draws a conclusion about why the client fell. Although sedative-hypnotics can cause confusion, it is inappropriate to assume that the medication was the cause. D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in medical record for further details. Rationale: This statement draws a conclusion about the cause of the client's injury. Unless the nurse witnessed the event, the nurse cannot be certain about how the injury occurred. In addition, it is inappropriate to refer to filing an incident report in the client's medical record.
(Answer) A. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only." Rationale: This statement presents data and nursing observations in a factual, non-judgmental manner about this incident. The nurse should also include vital signs, any additional findings, notification of the provider, treatments or procedures the provider prescribes, and the client's response.
47. A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia. Which of the following responses should the nurse make? (Answer) A. "Lochia can pool in the vagina while you lie in bed." Rationale: The client needs to be reassured that this is expected following a period of rest in bed. B. "You might have retained fragments of your placenta." Rationale: It is not likely that retained placenta fragments caused this release of lochia. C. "Urinary tract infections are associated with increased lochia." Rationale: It is not likely that an infection caused this release of lochia D. "The amount of lochia increases during the postpartum period." Rationale: The amount of lochia should decrease during postpartum uterine involution.
(Answer) A. "Lochia can pool in the vagina while you lie in bed." Rationale: The client needs to be reassured that this is expected following a period of rest in bed.
5. A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching? (Answer) A. "You'll have to remove metal objects such as watches and body jewelry." Rationale: The magnetic field of the scanner attracts metal objects such as jewelry and snaps or decorations on clothing. The field does not, however, attract materials made of steel or titanium. B."Your exposure to radiation will be minimal." Rationale: The client will not have any exposure to radiation during the MRI. C. "You will not be able to talk to the technician during the procedure." Rationale: The client will be able to communicate with the technician via a two-way communication system during the procedure. The technician can help guide the client through any feelings of claustrophobia. D. "Unlike an x-ray, the MRI allows you to move around a bit." Rationale: The client must remain still during the procedure.
(Answer) A. "You'll have to remove metal objects such as watches and body jewelry." Rationale: The magnetic field of the scanner attracts metal objects such as jewelry and snaps or decorations on clothing. The field does not, however, attract materials made of steel or titanium.
28. A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client? (Answer) A. A large amount of bright red vaginal bleeding without pain Rationale: With placenta previa, the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have sudden, painless vaginal bleeding, typically in the third trimester. B. Severe abdominal pain with increasing fundal height Rationale: Abdominal pain with increasing fundal height is associated with abruptio placenta. C. Abdominal pain with minimal red vaginal bleeding Rationale: Abdominal pain with vaginal bleeding is associated with abruptio placenta. D. Intermittent abdominal pain following passage of bloody mucus Rationale: Intermittent abdominal pain following passage of bloody mucus describes labor.
(Answer) A. A large amount of bright red vaginal bleeding without pain Rationale: With placenta previa, the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have sudden, painless vaginal bleeding, typically in the third trimester.
23. A nurse is collecting data from an older adult client who has been taking digoxin for the past several months. For which of the following manifestations of digoxin toxicity should the nurse monitor? (Answer) A. Anorexia Rationale: Clients who take digoxin are at risk for toxicity due to the medication's narrow therapeutic range. Anorexia, nausea, and vomiting are some of the early manifestations of digoxin toxicity in adults. In children, cardiac dysrhythmias are often the first manifestation of digoxin toxicity. B. Ataxia Rationale: Weakness is a manifestation of digoxin toxicity; however, ataxia, a lack of muscle coordination, is not present with digoxin toxicity. C. Hearing deficits Rationale: Digoxin toxicity causes halos around lights, yellow vision, and blurred vision; however, hearing deficits are not a manifestation of digoxin toxicity. D. Jaundice Rationale: Jaundice is a sign of sulfonylurea toxicity in older adults; however, jaundice is not a manifestation of digoxin toxicity.
(Answer) A. Anorexia Rationale: Clients who take digoxin are at risk for toxicity due to the medication's narrow therapeutic range. Anorexia, nausea, and vomiting are some of the early manifestations of digoxin toxicity in adults. In children, cardiac dysrhythmias are often the first manifestation of digoxin toxicity.
2. An older adult client falls and fractures her hip while a nurse is assisting her to the bathroom. The client sues the nurse for negligence. The nurse should identify which of the following principles as the standard that will legally determine her liability for the client's injury? (Answer) A. Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances Rationale: In court, the standard that determines negligence is how a reasonably prudent nurse with the same education and experience would have performed under the same circumstances. B. An expert nurse describes how the nurse could have handled the same situation differently. Rationale: Negligence is the actual conduct, not speculation about prevention, that falls below the standard. C. The plaintiffs attorney states that the nurse could have prevented the client's injury. Rationale: Negligence is the actual conduct, not speculation about prevention, which falls below the standard. D. The client's provider testifies that the client's condition required a different method of moving her. Rationale: Negligence is the actual conduct, not speculation about prevention, which falls below the standard.
(Answer) A. Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances Rationale: In court, the standard that determines negligence is how a reasonably prudent nurse with the same education and experience would have performed under the same circumstances.
14. A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action? (Answer) A. Check the client's vital signs. Rationale: The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Collecting additional data will provide the nurse with knowledge to make an appropriate decision. B. Notify the charge nurse. Rationale: Notifying the charge nurse or other appropriate nursing supervisor is an action the nurse should take; however, it is not the priority action. C. Fill out an occurrence report according to institutional policy. Rationale: Completing an occurrence form is an action the nurse should take in order to provide quality improvement within the facility; however, it is not the priority action. D. Document an objective description of what has happened in the client's chart. Rationale: The nurse should document an objective description of what has happened in the client's chart; however, it is not the priority action.
(Answer) A. Check the client's vital signs. Rationale: The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Collecting additional data will provide the nurse with knowledge to make an appropriate decision.
32. A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority? (Answer) A. Dry the newborn. Rationale: Drying the newborn is the priority action the nurse should take. Failure to dry the newborn can result in cold stress, which poses the greatest risk to the infant's safety. Cold stress increases oxygen demand and can result in respiratory distress and hypoglycemia. B. Administer phytonadione IM. Rationale: The nurse should administer phytonadione to the newborn shortly after birth. However, there is another action that is the priority. C. Document the Apgar score. Rationale: The nurse should document the newborn's Apgar score shortly after birth. However, there is another action that is the priority. D. Apply identification bands. Rationale: The nurse should apply identification bands on the newborn and parents shortly after birth. However, there is another action that is the priority.
(Answer) A. Dry the newborn. Rationale: Drying the newborn is the priority action the nurse should take. Failure to dry the newborn can result in cold stress, which poses the greatest risk to the infant's safety. Cold stress increases oxygen demand and can result in respiratory distress and hypoglycemia.
37. A nurse is reinforcing teaching with a client about checking her basal temperature to identify when ovulation occurs. The nurse should instruct the client to check her temperature at which of the following times? (Answer) A. Every morning before arising Rationale: The nurse should instruct the client to measure her temperature every morning throughout her menstrual cycle, upon waking, before getting out of bed. Activity or movement can raise body temperature slightly and provide inaccurate results. The client should use a special thermometer that is accurate to the tenth of a degree. B. Only on days 13 to 17 of her menstrual cycle Rationale: The client should not measure basal temperature on just these days because it will not provide sufficient information for monitoring temperature trends. C. 1 hr after vaginal intercourse Rationale: This is not the correct time of day for the client to measure basal temperature and will provide inaccurate information for monitoring temperature trends. D. Immediately after getting into bed at night Rationale: This is not the correct time of day for the client to measure basal temperature and will provide inaccurate information for monitoring temperature trends.
(Answer) A. Every morning before arising Rationale: The nurse should instruct the client to measure her temperature every morning throughout her menstrual cycle, upon waking, before getting out of bed. Activity or movement can raise body temperature slightly and provide inaccurate results. The client should use a special thermometer that is accurate to the tenth of a degree.
3. A nurse's inadvertent medication error results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following? (Answer) A. Malpractice Rationale:The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client. B. Assault Rationale: Assault, an intentional tort and a violation of civil law, is the threat to touch a person without consent. the nurse did not threaten to touch the client. C. Battery Rationalo: Battery, an intentional tort and a violation of civil law, is touching someone without consent. The nurse in this scenario did notouch the client without consent. D. Abuse Rationale: Abuse requires malicious intent. The nurse did not intend to harm this client.
(Answer) A. Malpractice Rationale:The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client.
16. A nurse is caring for a client who has a prescription for clopidogrel. Which of the following actions should the nurse plan to take? (Answer) A. Monitor the client for black, tarry stools. Rationale: Clopidogrel is an antithrombotic and antiplatelet medication; therefore, it poses a risk of serious bleeding. The nurse should monitor for signs of bleeding such as black, tarry stools and report these findings to the provider. B. Initiate contact precautions. Rationale: Contact precautions protect staff from acquiring an illness that spreads by direct contact, such as a methicillin-resistant Staphylococcus aureus infection. C. Administer the medication with each meal. Rationale: The nurse should administer clopidogrel once daily, with or without food. D. Have suction equipment at the bedside. Rationale: The nurse should have suction equipment at the bedside for a client who requires seizure precautions; however, this is not necessary for a client who is receiving this medication and is not otherwise at an increased risk for aspiration.
(Answer) A. Monitor the client for black, tarry stools. Rationale: Clopidogrel is an antithrombotic and antiplatelet medication; therefore, it poses a risk of serious bleeding. The nurse should monitor for signs of bleeding such as black, tarry stools and report these findings to the provider.
18. A nurse is caring for a client who has a new prescription for warfarin. The nurse should use the results of which of the following diagnostic tests to monitor the effect of this therapy? (Answer) A. Prothrombin time (PT) Rationale: The PT, reported as an INR, is used to monitor warfarin therapy. B. Platelet count Rationale: The platelet count is used to monitor for adverse effects of cancer chemotherapy. Warfarin does not affect the platelet count. C. White blood cell count (WBC) Rationale: The WBC is used to monitor antibiotic therapy for a client who has a bacterial infection. D. Activated partial thromboplastin time (aPTT) Rationale: The aPTT is used to monitor heparin therapy.
(Answer) A. Prothrombin time (PT) Rationale: The PT, reported as an INR, is used to monitor warfarin therapy.
9. A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority? (Answer) A. Temperature 38.2° C (100.8° F) Rationale:A fever can indicate an infection. Therefore, the priority finding to report is the client's Temperature. B. Respiratory rate 12/min Rationale: A respiratory rate of 12/min is within the expected reference range for an adult client. C. Hematocrit 45% Rationale: A hematocrit level of 45% is within the expected reference range. D. Urine specific gravity 1.015 Rationale: A urine specific gravity of 1.015 is within the expected reference range.
(Answer) A. Temperature 38.2° C (100.8° F) Rationale:A fever can indicate an infection. Therefore, the priority finding to report is the client's Temperature.
51.A nurse is reinforcing teaching with a client who is pregnant and has a prescription for Rho(D) immune globulin. Which of the following information should the nurse include? (Answer) A. This medication prevents the formation of Rh antibodies by a woman who is Rh-negative. Rationale: Giving Rho(D) immune globulin prevents the client's immune system from forming antibodies secondary to exposure to fetal blood during pregnancy or delivery. B. This medication destroys Rh antibodies in a woman who is Rh-negative. Rationale: Rho(D) immune globulin does not destroy antibodies. C. This medication destroys Rh antibodies in a newborn who is Rh-positive. Rationale:Rho(D) immune globulin does not destroy antibodies. D. This medication prevents the formation of RH antibodies in a newborn who is Rh-positive. Rationale:Rho(D) immune globulin does not prevent the formation of antibodies in a newborn.
(Answer) A. This medication prevents the formation of Rh antibodies by a woman who is Rh-negative. Rationale: Giving Rho(D) immune globulin prevents the client's immune system from forming antibodies secondary to exposure to fetal blood during pregnancy or delivery.
1. A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the clients temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated? (Answer) A. Urine specific gravity 1.034 Rationale: The client's urine specific gravity is elevated, reflecting concentrated urine, which is a manifestation of dehydration. B. Bounding pulse Rationale:A client who has dehydration would have a weak pulse. C. BP 146/94 mm Hg Rationale: A client who has dehydration would have hypotension. D. Distended neck veins Rationale: Neck vein distention is a manifestation of fluid-volume excess, not dehydration.
(Answer) A. Urine specific gravity 1.034 Rationale: The client's urine specific gravity is elevated, reflecting concentrated urine, which is a manifestation of dehydration.
17.A nurse is collecting data from a client who has a prescription for oral clindamycin hydrochloride. Which of the following findings should the nurse immediately report to the provider? (Answer) A. Watery diarrhea Rationale: The greatest risk to this client who is taking clindamycin hydrochloride is colitis, ranging from mild diarrhea to a severe, life-threatening condition called pseudomembranous colitis. Watery diarrhea might be a manifestation of pseudomembranous colitis; therefore, this is the priority finding to report to the provider. B. Nausea Rationale: The nurse should monitor the client for nausea, an adverse effect of clindamycin hydrochloride; however, this is not the priority finding to report. C. Abdominal bloating Rationale: The nurse should monitor the client for abdominal bloating, an adverse effect of clindamycin hydrochloride; however, this is not the priority finding to report. D. Pruritus Rationale: The nurse should monitor the client for pruritus, an adverse effect of clindamycin hydrochloride; however, this is not the priority finding to report.
(Answer) A. Watery diarrhea Rationale: The greatest risk to this client who is taking clindamycin hydrochloride is colitis, ranging from mild diarrhea to a severe, life-threatening condition called pseudomembranous colitis. Watery diarrhea might be a manifestation of pseudomembranous colitis; therefore, this is the priority finding to report to the provider.
13. A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make? A. "Keep your eye open for 30 sec after instilling the ointment." Rationale: The nurse should instruct the client to close the eyelids without squeezing them shut to spread the medication over the eyeball. (Answer) B. "Apply the ointment in a thin line into the conjunctival sac." Rationale: This is the correct procedure for applying ophthalmic ointment. The medication should be administered (in a thin line) into the conjunctival sac, rather than being placed directly on the globe of the eye. This ensures that more of the medication meels the surfaces of the eye when the client blinks. C. "Always wipe from the outer to the inner canthus when wiping away secretions." Rationale: The client should be advised to wipe from the inner canthus (closer to the nose) to the outer canthus (closer to the ear) to avoid cross-contamination of the lacrimal duct and unaffected eye with infectious secretions. D. "Use a sterile glove and applicator to apply the antibiotic ointment." Rationale: Ophthalmic ointments are applied directly from the tube, using clean technique. The tube should not be allowed to touch the eye, and it should be recapped as soon as the ointment has been dispensed.
(Answer) B. "Apply the ointment in a thin line into the conjunctival sac." Rationale: This is the correct procedure for applying ophthalmic ointment. The medication should be administered (in a thin line) into the conjunctival sac, rather than being placed directly on the globe of the eye. This ensures that more of the medication meels the surfaces of the eye when the client blinks.
45.A nurse is reinforcing teaching about diaphragms with a client. Which of the following statements by the client indicates an understanding of the teaching? A. "I will coat the diaphragm with an oil-based lubricant in between uses." Rationale: Oil-based lubricants should not be used on the diaphragm because they can break down the rubber. (Answer) B. "I will leave the diaphragm in for at least 6 hours after vaginal intercourse." Rationale: The diaphragm must be left in place for 6 to 8 following after vaginal intercourse to be effective. For subsequent vaginal intercourse during this 6 to 8-hr time period, additional spermicidal jelly must be added without disturbing the placement of the diaphragm. C."I will avoid using creams or jellies so that the diaphragm will fit snugly." Rationale: Creams and jellies are recommended to use with a diaphragm to offer better protection against pregnancy. D. "I will need to get a new diaphragm every year." Rationale: The client should see their provider once a year to ensure proper fitting of the diaphragm and replace the diaphragm every 2 years.
(Answer) B. "I will leave the diaphragm in for at least 6 hours after vaginal intercourse." Rationale: The diaphragm must be left in place for 6 to 8 following after vaginal intercourse to be effective. For subsequent vaginal intercourse during this 6 to 8-hr time period, additional spermicidal jelly must be added without disturbing the placement of the diaphragm.
36. A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate? A "There are so many variables that you'll have to ask your provider". Rationale- This illustrates the non therapeutic reply of putting the clients concerns on hold. A nurse in the labor and delivery suite or on the postpartum unit should be able to provide the client with information that answers the question. (Answer) B. "The primary consideration is what type of incision you had." Rationale: A transverse incision (also known as a horizontal incision) cuts across the lower, thinner part of the uterus. It is used during most cesarean births and makes a VBAC possible. A vertical incision cuts up and down through the uterine muscles that strongly contract during labor and might cause uterine rupture during a VBAC. C. "It's too soon for you to be worrying about that now." Rationale: This nontherapeutic reply defers and devalues the client's concerns. D. "A repeat cesarean section would be safer for both you and your baby." Rationale: Research has shown that for most clients, VBAC is safe for both the mother and the baby.
(Answer) B. "The primary consideration is what type of incision you had." Rationale: A transverse incision (also known as a horizontal incision) cuts across the lower, thinner part of the uterus. It is used during most cesarean births and makes a VBAC possible. A vertical incision cuts up and down through the uterine muscles that strongly contract during labor and might cause uterine rupture during a VBAC.
20. A nurse is reinforcing discharge teaching with a client who has asthma and a new prescription for salmeterol. Which of the following instructions should the nurse include? A. "You can take an extra dose of salmeterol if an asthma attack begins." Rationale: Salmeterol is inhaled twice daily, approximately every 12 hr. It is not effective in stopping an acute asthma attack. (Answer) B. "This medication will provide long-term control of your asthma symptoms." Rationale: Salmeterol is an inhaled, long-acting beta-2 adrenergic agonist used to treat severe persistent asthma. When used every day as prescribed, salmeterol decreases the number and severity of asthma attacks. Salmeterol is prescribed along with a glucocorticoid medication, which adds an anti-inflammatory effect to the client's asthma treatment. C. "Once your symptoms have improved, you should discontinue use of this medication." Rationale: Salmeterol is used for long-term control of asthma and should be taken on a regular basis. D. "Salmeterol is an anti-inflammatory medication that decreases mucous secretion." Rationale: Salmeterol is a beta-adrenergic agonist that promotes bronchodilation.
(Answer) B. "This medication will provide long-term control of your asthma symptoms." Rationale: Salmeterol is an inhaled, long-acting beta-2 adrenergic agonist used to treat severe persistent asthma. When used every day as prescribed, salmeterol decreases the number and severity of asthma attacks. Salmeterol is prescribed along with a glucocorticoid medication, which adds an anti-inflammatory effect to the client's asthma treatment.
7. A charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene? A. "It will be easier to use your non-dominant hand to spread the labia." Rationale: The client should use her nondominant hand to provide access to urethral meatus, leaving the dominant hand to maneuver the specimen container. (Answer) B. "Use the provided towelette to cleanse the area by moving in a back-and-forth motion." Rationale: The client should use a new towelette each time to cleanse from an area of least contamination (front) to an area of greater contamination (back). C. "Start the flow of urine before passing the container under the stream to collect the specimen. Rationale: This action prevents contamination of specimens by allowing the first flow of urine to wash away dirty surface area before securing a urine sample. D. "Remove the specimen container before stopping the stream of urine." Rationale: This action prevents the introduction of vaginal or perineal area bacteria into the specimen.
(Answer) B. "Use the provided towelette to cleanse the area by moving in a back-and-forth motion." Rationale: The client should use a new towelette each time to cleanse from an area of least contamination (front) to an area of greater contamination (back).
11. A nurse is assisting with the development of an education program for a community group about intake of vitamins and minerals in the diet. Which of the following foods should the nurse recommend as the best source of vitamin C? A. ½ cup green pepper Rationale- The nurse should determine that one half cup of green pepper has 60 mg of vitamin C per serving; however this is not the best source of vitamin C. (Answer) B. 1 medium orange Rationale: The nurse should determine that one medium orange is the best source to recommend because oranges contain 80 mg of vitamin C per serving. C. ½ cup cabbage Rationale: The nurse should determine that one half cup of cabbage has 33 mg of vitamin C per serving; however, this is not the best source of vitamin C. D. 1 medium tomato Rationale: The nurse should determine that one medium tomato has 17 mg of vitamin C per serving; however, this is not the best source of vitamin C.
(Answer) B. 1 medium orange Rationale: The nurse should determine that one medium orange is the best source to recommend because oranges contain 80 mg of vitamin C per serving.
6. A nurse is assisting a client who has generalized weakness out of bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheelchair at a 90° angle to the bed. Rationale: If the client has difficulty walking, the nurse should place the wheelchair parallel to the bed. (Answer) B. Lock the wheels of the bed and the wheelchair. Rationale: The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving when transferring a client. C. Get the help of several staff members to lift the client. Rationale: There is no indication that the client is so weak that the staff must lift him. If the client requires lifting, then the nurse should use the appropriate lifting device to keep the client and the staff safe. D. Elevate the bed to a position of comfort for the nurse. Rationale: When assisting the client out of bed, the nurse should lower the bed to its lowest position.
(Answer) B. Lock the wheels of the bed and the wheelchair. Rationale: The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving when transferring a client.
40. A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage? A. Two-vessel umbilical cord Rationale: The presence of a two-vessel umbilical cord does not increase a client's risk for a postpartum hemorrhage. (Answer) B. Precipitous birth Rationale: A client who has a precipitous birth is at an increased risk for postpartum hemorrhage. C. Small for gestational age newborn Rationale- A client who has a newborn that is small for gestational age is not at an increased risk for the postpartum hemorrhage. A client who gives birth to a large newborn is at an increased risk. D. Gestational hypertension Rationale: Gestational hypertension does not increase a client's risk for a postpartum hemorrhage
(Answer) B. Precipitous birth Rationale: A client who has a precipitous birth is at an increased risk for postpartum hemorrhage.
38. A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include? A. Given too soon, epidural anesthesia can cause fetal depression." Rationale: Epidural anesthesia administered during labor and birth has little or no effect on the newborn. B. "Given too soon, epidural anesthesia will delay rupture of fetal membranes." Rationale: An epidural will not affect when the fetal membranes rupture. (Answer) C. "Given too soon, epidural anesthesia can prolong labor." Rationale- Progress in labor slows when clients are given anesthesia before the active phase of labor. The medication depresses the central nervous system, thus it will take longer for the cervix to dilate and efface. D. "Given too soon, epidural anesthesia can cause maternal hypertension. Rationale: Epidural anesthesia reduces maternal blood pressure because of central nervous system depression.
(Answer) C. "Given too soon, epidural anesthesia can prolong labor." Rationale- Progress in labor slows when clients are given anesthesia before the active phase of labor. The medication depresses the central nervous system, thus it will take longer for the cervix to dilate and efface.
27.A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have an immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times? A. When she does not desire future pregnancies Rationale: A delay in receiving the MMR vaccine places the client at risk for contracting the illness. (Answer) B. Prior to discharge from the hospital after giving birth Rationale: The nurse should recommend the client receive the MMR vaccine following delivery, so she is protected from contracting rubella then and during any subsequent pregnancies. C. Prior to giving birth Rationale: Pregnancy is a contraindication for receiving the MMR vaccine. D. Two weeks before attempting pregnancy again Rationale: The MMR vaccine must be given at least 3 months prior to pregnancy to ensure that the developing fetus is not exposed to the rubella virus. The client should avoid becoming pregnant for at least 28 days after receiving the vaccine.
(Answer) B. Prior to discharge from the hospital after giving birth Rationale: The nurse should recommend the client receive the MMR vaccine following delivery, so she is protected from contracting rubella then and during any subsequent pregnancies.
21. A nurse is reinforcing teaching for a client who has a new prescription for warfarin. Which of the following information should the nurse include? A. Mild nosebleeds are common during initial treatment. Rationale: Warfarin, an anticoagulant, increases the client's risk for bleeding. The nurse should instruct the client to stop the medication and notify the provider if bleeding occurs. (Answer) B. The client should use an electric razor while on this medication. Rationale: Warfarin, an anticoagulant, increases the client's risk for bleeding. The nurse should teach the client safety measures, such as using an electric razor, to decrease the risk for injury and bleeding. C. If he misses a dose, he should double the dose at the next scheduled time. Rationale: Warfarin, an anticonvulsant, should be taken at the same time each day and the client should not adjust the dose. Doubling a dose increases the client's risk for bleeding. D. Warfarin increases the risk for deep vein thrombosis. Rationale: Warfarin, an anticoagulant, is a medication for the prophylaxis and treatment of deep vein thrombosis.
(Answer) B. The client should use an electric razor while on this medication. Rationale: Warfarin, an anticoagulant, increases the client's risk for bleeding. The nurse should teach the client safety measures, such as using an electric razor, to decrease the risk for injury and bleeding.
30. A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching? A. Expect your baby to have less than 5 wet diapers per day after the fourth day of life. Rationale: The nurse should instruct the mother that ineffective breastfeeding is indicated by the infant having less than six wet diapers per day after the fourth day of life, and to notify the provider. (Answer) B. Your baby can lose 5% of body weight during the first 3 days of life. Rationale: The nurse should instruct the mother that the baby can have a weight loss between 5% and 6% of their birth weight during the first 3 days of life. Breastfed infants usually regain birth weight by their second or third week of life. C. Your baby should gain 0.25 oz (7 grams) per day after the fourth day of life. Rationale: The nurse should instruct the mother that the baby should gain at least 0.5 oz (14 g) per day after the fourth day of life. D. Expect your baby to feed constantly the first week of life. Rationale: The nurse should instruct the mother that if the baby is feeding constantly, breast feeding may be ineffective and should notify the provider.
(Answer) B. Your baby can lose 5% of body weight during the first 3 days of life. Rationale: The nurse should instruct the mother that the baby can have a weight loss between 5% and 6% of their birth weight during the first 3 days of life. Breastfed infants usually regain birth weight by their second or third week of life.
48. A nurse is reinforcing teaching with a client who is at 17 weeks of gestation and is scheduled to have a maternal serum alpha-fetoprotein (MSÄFP) determination. Which of the following information should the nurse include? A. This test will screen for gestational diabetes. Rationale: A glucose tolerance test screens for gestational diabetes. (Answer) B.This test will screen for neural tube defects. Rationale: MSAFP measures blood levels of alpha-fetoprotein in the client's blood. Abnormal levels can indicate a neural tube defect, such as spina bifida, as well as multifetal pregnancies and fetal abdominal wall defects. C. This test will screen for fetal maturity. Rationale: Fetal maturity is generally determined with tests performed on amniotic fluid and with Ultrasonography. D. This test will screen for ABO incompatibility. Rationale: Blood typing helps determine AB incompatibility.
(Answer) B.This test will screen for neural tube defects. Rationale: MSAFP measures blood levels of alpha-fetoprotein in the client's blood. Abnormal levels can indicate a neural tube defect, such as spina bifida, as well as multifetal pregnancies and fetal abdominal wall defects.
22. A nurse is assisting in the education of a group of clients about the contraindications of warfarin therapy. Which of the following statements is appropriate to include in the instructions? A. "Clients who have diabetes mellitus type 1 should not take warfarin." Rationale: Diabetes mellitus is not a contraindication for warfarin therapy. B. "Clients who have rheumatoid arthritis should not take warfarin." Rationale: Rheumatoid arthritis is not a contraindication for warfarin therapy. (Answer) C. "Clients who are pregnant should not take warfarin." Rationale: Warfarin therapy is contraindicated in the pregnant client because it crosses the placenta and places the fetus at risk. Warfarin is a pregnancy category X medication. D. "Clients who have hypertension should not take warfarin." Rationale: Hypertension is not a contraindication for warfarin therapy.
(Answer) C. "Clients who are pregnant should not take warfarin." Rationale: Warfarin therapy is contraindicated in the pregnant client because it crosses the placenta and places the fetus at risk. Warfarin is a pregnancy category X medication.
39. A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborns' hydration. Which of the following nursing observations are appropriate to use in evaluating the adequacy of the newborns hydration? A. The fit of the newborn's clothes Rationale: The fit of the newborn's clothes is an inappropriate evaluation tool for hydration. B. How often the newborn cries Rationale: Newborns cry for reasons other than hunger or dehydration. C. The newborn's skin turgor Rationale: Skin turgor is not lost in the early stages of dehydration. (Answer) D. The number of wet diapers per day Rationale: The easiest and most reliable method to evaluate hydration is urinary output. Six to eight wet diapers per day is generally considered adequate.
(Answer) D. The number of wet diapers per day Rationale: The easiest and most reliable method to evaluate hydration is urinary output. Six to eight wet diapers per day is generally considered adequate.
24. A nurse is reinforcing teaching for a client who has diabetes mellitus and has a prescription for insulin detemir injections once daily. Which of the following statements by the client indicates an understanding of the teaching? A. "If my blood sugar is high, I can mix a dose of regular insulin with my insulin detemir." Rationale: Insulin detemir should not be mixed with any other insulin in the same syringe. B. "I should inject by insulin detemir 30 min before a meal to lower my blood sugar." Rationale: Insulin detemir is absorbed slowly and does not need to be taken before a meal. (Answer) C. "I can inject my insulin detemir in the evening before bedtime." Rationale: When prescribed once daily, insulin detemir is injected in the evening, either with the evening meal or at bedtime D. "I don't have to worry about hypoglycemia while taking insulin detemir. " Rationale: As with other types of insulin, the client should be instructed to monitor for hypoglycemia when taking insulin detemir and should also learn how to manage manifestations of hypoglycemia.
(Answer) C. "I can inject my insulin detemir in the evening before bedtime." Rationale: When prescribed once daily, insulin detemir is injected in the evening, either with the evening meal or at bedtime
46.A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate? A. "Come to the office and we will check things out. Rationale: The client's manifestations do not indicate the client should be seen by the provider. B."Go to the emergency room and your provider will meet you there." Rationale: The client's manifestations do not indicate the client should be seen by the provider. (Answer) C. "This is expected because of the way iron is broken down during digestion. Rationale: Iron supplements turn a client's stools black. In the absence of cramping and abdominal pain, this is an expected finding. The client should be instructed to expect black stools. D. "What else have you been eating?" Rationale: The client's manifestations do not indicate that a food could have caused the black stools.
(Answer) C. "This is expected because of the way iron is broken down during digestion. Rationale: Iron supplements turn a client's stools black. In the absence of cramping and abdominal pain, this is an expected finding. The client should be instructed to expect black stools.
12. A nurse is conducting nutritional counseling with a client who is in her second trimester of pregnancy. Which of the following amounts of an increase in caloric intake should the nurse recommend to the client during the second trimester? A. 110 cal/day Rationale: An increase of 110 cal/day is not enough for a client in her second trimester, because the client may start having weight loss dung the pregnancy. B. 225 cal/day Rationale: An increase of 225 cal/day is not enough for a client in her second trimester, because the client may start having weight loss during the pregnancy. (Answer) C. 340 calday Rationale: The nurse should recommend to the client to increase her calorie intake by 340 cal/day in order to have a weight gain of one pound per week during the pregnancy. D. 450 cal/day Rationale: An increase of 450 cal/day may cause the client to gain too much weight during the second trimester of the pregnancy.
(Answer) C. 340 calday Rationale: The nurse should recommend to the client to increase her calorie intake by 340 cal/day in order to have a weight gain of one pound per week during the pregnancy.
33.A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform? A. Encourage the client to nurse more frequently so her milk will come in. Rationale: This is not an appropriate action; the breasts are expected to be soft after delivery. B. Report the client's temperature elevation. Rationale: A temperature up to 38° C (100.4° F) following delivery is often the result of dehydration. Once the client is hydrated, the temperature is expected to return to normal. (Answer) C. Ask the client to empty her bladder. Rationale: Whenever the funds is deviated from the midline, a full bladder should be considered as a potential cause. A full bladder could result in complications such as uterine atony or infection. D. Increase IV fluids. Rationale: Increasing the IV fluids is not indicated for this client.
(Answer) C. Ask the client to empty her bladder. Rationale: Whenever the funds is deviated from the midline, a full bladder should be considered as a potential cause. A full bladder could result in complications such as uterine atony or infection.
44. A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take? A. Place the client on seizure precautions. Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. Placing the client on seizure precautions is not an appropriate action. B. Notify the charge nurse. Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. Notifying the charge nurse of the finding is not an appropriate response. (Answer) C. Cover the client with warm blankets. Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. The nurse should cover the client with a warm blanket following delivery. D. Determine the client's temperature. Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. Determining the client's temperature is not an appropriate action.
(Answer) C. Cover the client with warm blankets. Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. The nurse should cover the client with a warm blanket following delivery.
29. A nurse is preparing to administer dinoprostone gel to a client who is pregnant. The client asks the nurse about the purpose of the medication. Which of the following responses should the nurse make? A. Dinoprostone stimulates uterine contractions. Rationale: This medication does not stimulate uterine contractions. Medications such as oxytocin stimulate uterine contractions. B. Dinoprostone assists with ending the pregnancy. Rationale: This medication does not cause a client to abort a fetus. Medications such as misoprostol cause the client to abort the pregnancy. (Answer) C. Dinoprostone promotes softening of the cervix. Rationale: Dinoprostone is used to prepare or soften the cervix for the induction of labor in pregnant clients who are at or near term. D. Dinoprostone relaxes uterine contractions. Rationale: This medication is not used to relax uterine contractions. Tocolytics relax uterine contractions.
(Answer) C. Dinoprostone promotes softening of the cervix. Rationale: Dinoprostone is used to prepare or soften the cervix for the induction of labor in pregnant clients who are at or near term.
42. A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations? A. Decreased energy Rationale:A reduced energy level is an expected manifestation of first-trimester pregnancy. B. Urinary frequency Rationale: Urinary frequency is an expected manifestation of first-trimester pregnancy. (Answer) C. Facial edera Rationale: Facial edema is an indication of pregnancy-induced hypertension, which should be reported to the client's provider. D. Mood swings Rationale: Mood swings are an expected manifestation of pregnancy.
(Answer) C. Facial edera Rationale: Facial edema is an indication of pregnancy-induced hypertension, which should be reported to the client's provider.
35. A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse? A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old Rationale:A blood glucose of 40 mg/dL for a 1-hr-old infant is within the expected reference range. B. Acrocyanosis in an infant who is 2-hr old Rationale: Acrocyanosis is a normal characteristic of a newborn's circulatory system. Acrocyanosis disappears within 24 to 48 hr after birth. (Answer) C. Jaundice in an infant who is 4-hr old Rationale: Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and requires notifying the charge nurse immediately. D. A hematocrit of 60% in an infant who is 8-hr old Rationale: Infant hematocrit is high during the first few days after birth due to increased red blood cells received from the mother and from the infant's own production of red blood cells after birth.
(Answer) C. Jaundice in an infant who is 4-hr old Rationale: Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and requires notifying the charge nurse immediately.
50. A nurse is caring for a client who is at 32 weeks of gestation and is in labor; Which of the following medications is contraindicated for this client? A. Folic acid Rationale: Folic acid is given to clients who are pregnant to prevent neural tube defects. B. Nifedipine Rationale: Nifedipine relaxes uterine smooth muscle and is often used to treat preterm labor. (Answer) C. Misoprostol Rationale: Misoprostol can cause abortion, premature labor, and birth defects. This prescription should be clarified with the provider. D. Terbutaline sulfate Rationale: Terbutaline relaxes uterine smooth muscle and is often used to treat preterm labor.
(Answer) C. Misoprostol Rationale: Misoprostol can cause abortion, premature labor, and birth defects. This prescription should be clarified with the provider.
25.A nurse is collecting data from a client who takes metformin for type 2 diabetes. Which of the following medications is contraindicated for this client due its effect on blood glucose levels? A. Ranitidine Rationale: Medications that increase plasma glucose levels are contraindicated for this client. Ranitidine can cause a reversible decrease in the WBC but does not affect blood glucose levels. B. Cephalexin Rationale: Medications that increase plasma glucose levels are contraindicated for this client. Cephalexin can cause a false- positive urine glucose test result but does not affect blood glucose levels. (Answer) C. Prednisone Rationale: Medications that increase plasma glucose levels are contraindicated for this client. Corticosteroids, such as prednisone, increase plasma levels of glucose levels and cause hyperglycemia and glycosuria. D. Levothyroxine Rationale: Medications that increase plasma glucose levels are contraindicated for this client. Levothyroxine can cause insomnia and headaches but does not affect blood glucose levels.
(Answer) C. Prednisone Rationale: Medications that increase plasma glucose levels are contraindicated for this client. Corticosteroids, such as prednisone, increase plasma levels of glucose levels and cause hyperglycemia and glycosuria.
10. A nurse is reinforcing teaching with a client who is lactose intolerant. Which of the following statements should the nurse include in the teaching? A. You should increase the fiber in your diet." Rationale: An increase of fiber in the diet will not affect lactose intolerant symptoms. B. "You should increase the calories in your diet. Rationale: Increasing calories in the diet will not affect lactose intolerant symptoms. (Answer) C. You should decrease the dairy products in your diet." Rationale: A decrease in dairy products will reduce the symptoms associated with lactose intolerance. D. "You should decrease the amount of vitamin D in your diet." Rationale: A decrease of vitamin D in the diet will not affect lactose intolerant symptoms. Although vitamin D often accompanies dairy products, which the client should avoid consuming, there are other ways for the client to consume vitamin D.
(Answer) C. You should decrease the dairy products in your diet." Rationale: A decrease in dairy products will reduce the symptoms associated with lactose intolerance.
19. A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. The nurse should recognize that which of the following statements by the client indicates a need for further teaching? "I will notify my provider before taking any other medications." Rationale: Many medication interactions can occur with phenytoin, so the client should contact the provider before taking a new medication. B. "I have made an appointment to see my dentist next week." Rationale: The client understands that phenytoin can cause an overgrowth of the gum tissue; therefore good oral hygiene and dental monitoring is important. C. "I will take this medication with meals." Rationale: Phenytoin should be taken with meals to reduce the occurrence of gastrointestinal distress. (Answer) D. "I'll be glad when my seizures stop so I can quit taking this medicine." Rationale: The client should not discontinue the phenytoin abruptly, because withdrawal from treatment can cause seizures to resume. Clients taking anticonvulsant medications often require them for life, and phenytoin should not be stopped unless indicated by the provider.
(Answer) D. "I'll be glad when my seizures stop so I can quit taking this medicine." Rationale: The client should not discontinue the phenytoin abruptly, because withdrawal from treatment can cause seizures to resume. Clients taking anticonvulsant medications often require them for life, and phenytoin should not be stopped unless indicated by the provider.
49. A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation. The client reports urinary frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following responses by the nurse is appropriate? A. Yes, it will, but if you decrease your fluid intake, especially at bedtime, it won't be so bothersome." Rationale: Fluid intake should not be restricted during pregnancy. B. "No, in most cases it only lasts until about the 12th week, but it will continue if you have poor bladder tone." Rationale: The presence or absence of bladder tone has no effect on urinary frequency during pregnancy. C. There is no way to predict how long it will last for each individual client, so you'll just have to wait and see." Rationale: This statement is not helpful to the client, as it does not address the client's immediate concems. (Answer) D. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy." Rationale: Urinary frequency usually disappears at about 12 weeks of gestation but returns near term as the enlarging uterus presses on the bladder. It can also worsen following fetal descent.
(Answer) D. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy." Rationale: Urinary frequency usually disappears at about 12 weeks of gestation but returns near term as the enlarging uterus presses on the bladder. It can also worsen following fetal descent.
15. A nurse is preparing to administer IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse plan to take? A. Change the IV site with each new dose. Rationale: The nurse should monitor the IV site closely for manifestations of thrombophlebitis and change the infusion site frequently; however, the infusion site does not need to be changed with each dose. B. Inform the client to expect urine to become pink in color. Rationale: This is not an appropriate action. The client should not expect his urine to become pink in color. C. Administer the medication with an NSAID to minimize infusion discomfort. Rationale: Nephrotoxic medications, including NSAIDs, can increase the risk of kidney damage. The nurse should not give these medications concurrently. (Answer) D. Infuse the medication over at least 60 min. Rationale: Rapid infusion of vancomycin can cause a phenomenon known as Red Man syndrome. The nurse can minimize the risk of this from occurring by slowly infusing the medication over a period of 60 min or longer.
(Answer) D. Infuse the medication over at least 60 min. Rationale: Rapid infusion of vancomycin can cause a phenomenon known as Red Man syndrome. The nurse can minimize the risk of this from occurring by slowly infusing the medication over a period of 60 min or longer.
34. A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation, which of the following findings should the nurse expect? A. Uterine enlargement greater than expected for gestational age Rationale: In an ectopic pregnancy, the egg is implanted in the fallopian tube instead of the uterus. This is not an expected finding for this client. B. Copious vaginal bleeding Rationale: Vaginal spotting is an expected finding for a client who has an ectopic pregnancy. C. Severe nausea and vomiting Rationale: The client might have an expected amount of nausea and vomiting associated with pregnancy. (Answer) D. Pelvic pain Rationale: The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing pain as the tube stretches.
(Answer) D. Pelvic pain Rationale: The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing pain as the tube stretches.
31.A nurse in a provider's office is reinforcing teaching about home care with a client who has mild preeclampsia. Which of the following information should the nurse include in the teaching? A. Rest in bed in the supine position. Rationale: The client should rest in bed in the lateral recumbent position to prevent pressure on the vena cava. Lying in the supine position can cause supine hypotension due to the weight of the uteru on the superior vena cava. B. Limit sodium intake to 2,000 mg/day. Rationale: The client should consume no more than 1,500 mg of sodium per day. She should maintain a regular dietary intake with adequate amounts of protein, sodium, and water intake. The client should salt foods to taste while avoiding excessively salty foods, such as pretzels and Sauerkraut. C. Limit fluid intake to 1,000 mL/day. Rationale: The client should drink six to eight 8-oz glasses of water (1,440-1,920 mL) per day to enhance renal perfusion and prevent constipation. (Answer) D. Perform daily fetal movement counts. Rationale: The client should count the number of fetal movements felt in one hour, preferably after a meal. Fetal movements are a reassuring sign of fetal oxygenation. The client should notify the provider if less than 3 movements per hour are noted, as this warrants further evaluation.
(Answer) D. Perform daily fetal movement counts. Rationale: The client should count the number of fetal movements felt in one hour, preferably after a meal. Fetal movements are a reassuring sign of fetal oxygenation. The client should notify the provider if less than 3 movements per hour are noted, as this warrants further evaluation.
8. A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first? (Answer)A. Encourage the client to cough and deep breathe. Rationale- when using the airway, breathing, circulation approach to client care, the nurse should place the priority on the client's airway. Therefore the nurse should encourage the client to cough and deep breath to clear secretions. B. Obtain the client's temperature. Rationale: The nurse should monitor the temperature of a client who has pneumonia to alert the nurse to the development of a secondary bacterial infection but there is another action the nurse should take first. C. Encourage the client to increase oral fluids. Rationale: The nurse should instruct the client to increase oral fluids to thin the secretions, but there is another action the nurse should take first. D. Provide chest percussion on the client. Rationale: The nurse can provide chest percussion on the client if other methods are not successful to clear the client's secretions, but there is another action the nurse should take first.
(Answer)A. Encourage the client to cough and deep breathe. Rationale- when using the airway, breathing, circulation approach to client care, the nurse should place the priority on the client's airway. Therefore the nurse should encourage the client to cough and deep breath to clear secretions.
43.A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn umbilical cord? A. One artery and one vein Rationale: This is not the correct number of veins and arteries. (Answer)B. Two arteries and one vein Rationale: The vein carries oxygenated blood to the fetus, and the two arteries carries unoxygenated blood back to the placenta. C. Two veins and one artery Rationale: This is not the correct number of veins and arteries. D. Two arteries and two veins Rationale: This is not the correct number of veins and arteries.
(Answer)B. Two arteries and one vein Rationale: The vein carries oxygenated blood to the fetus, and the two arteries carries unoxygenated blood back to the placenta.
26.A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The funds is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Assist the client to ambulate. Rationale: The nurse is not addressing the client's needs by assisting her to ambulate; therefore, this is not an appropriate action for the nurse to take. B. Perform fundal massage. Rationale: The nurse notes that the funds is midline and firm; therefore, fundal massage is not indicated at this time. C. Increase the rate of the IV fluids. Rationale: There is no indication that the client requires extra fluid; therefore, this is not an appropriate action for the nurse to take. (Answer)D. Check for blood under the client's buttock. Rationale: The nurse should check for blood under the client's buttock to evaluate the amount of lochia flow and to check for pooling of blood that would otherwise be missed.
(Answer)D. Check for blood under the client's buttock. Rationale: The nurse should check for blood under the client's buttock to evaluate the amount of lochia flow and to check for pooling of blood that would otherwise be missed.
