Final exam Nurs351

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What symptom described by a woman is characteristic of premenstrual syndrome (PMS)? "I feel irritable and moody a week before my period is supposed to start." "I have lower abdominal pain beginning the third day of my menstrual period." "I have nausea and headaches after my period starts, and they last 2 to 3 days." "I have abdominal bloating and breast pain after a couple days of my period."

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? Administer oxygen Notify the health care provider Rapidly administer more IV fluid Reposition the patient on the right side

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: encouraging the woman to try various upright positions, including squatting and standing. telling the woman to start pushing as soon as her cervix is fully dilated. continuing an epidural anesthetic so that pain is reduced and the woman can relax. coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

When planning a diet with a pregnant woman, the nurse's FIRST action would be to: review the woman's current dietary intake. teach the woman about the food pyramid. caution the woman to avoid large doses of vitamins, especially those that are fat-soluble. instruct the woman to limit the intake of fatty foods.

When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? "I will need to isolate any tissues I use so as not to infect my family." "I will notify all of my sexual partners so they can get tested for HIV." "Unprotected sexual contact is the most common mode of transmission." "I do not need to worry about spreading this virus to others by sweating at the gym."

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? Absence of pain or pressure Blurred vision in the morning Seeing colored halos around lights Eye pain accompanied with nausea and vomiting

Which intervention will best establish a military personnel's mental health fitness for deployment to a war zone? a. Conducting a predeployment mental health screening as part of the general physical examination b. Reviewing the military performance records prior to deployment for identification of possible risk factors c. Providing each military personnel with the opportunity to confidentially discuss their individual concerns with a mental health professional d. Asking the military personnel to identify in writing any history of mental illness including depression, anxiety, or substance dependency issues

Which nursing diagnosis is priority when caring for a patient with renal calculi? Acute pain Risk for constipation Deficient fluid volume Risk for powerlessness

Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? 3.1 mEq/L 3.9 mEq/L 4.6 mEq/L 5.3 mEq/L

Which statement regarding continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? "Maintain a daily written record of blood pressure and weight." "It is essential that you maintain aseptic technique to prevent peritonitis." "You will be allowed a more liberal protein diet once you complete CAPD." "Continue regular medical and nursing follow-up visits while performing CAPD."

With regard to dysfunctional uterine bleeding (DUB), the nurse should be aware that: it is most commonly caused by anovulation. it most often occurs in middle age. the diagnosis of DUB should be the first considered for abnormal menstrual bleeding. the most effective medical treatment involves steroids.

The nurse should include which instructions when teaching a mother about the storage of breast milk? (Select all that apply.) Wash hands before expressing breast milk. Store milk in 8 to 12 oz containers. Store refrigerated milk in the door of the refrigerator. Place frozen milk in the microwave for only a few seconds to thaw. Milk thawed in the refrigerator can be stored for 24 hours.

A, E

The nurse provides nutritional counseling for a 45-yr-old man with nephrotic syndrome. The nurse determines teaching has been successful if the patient selects which breakfast menu? Scrambled eggs, milk, yogurt, and sliced ham Oatmeal, nondairy creamer, banana, and orange juice Cottage cheese, peanut butter, white bread, and coffee Waffle, bacon strips, tomato juice, and canned peaches

The nurse understand that the action of antidiuretic hormone (ADH) is to: a) reduce blood volume b) decrease water loss in the urine c) increase urine output d) trigger the thirst mechanism

The patient informs the nurse that he has a "sty" that has been present for some time on the upper eyelid and reports using warm moist compresses with no improvement. What is the best response by the nurse? "Go to the pharmacy to get some eye drops." "Come in so the ophthalmologist can assess the lesion." "The health care provider will need to inject it with an antibiotic." "Wash the eyelid margins with baby shampoo to remove the crusting.

The patient is being treated for a recurrent episode of Chlamydia. What should the nurse include in patient teaching? If you are treated, your sexual partner will not need to be treated. Abstain from sexual intercourse for 7 days after finishing the treatment. You will probably get gonorrhea if you have another recurrence of Chlamydia. Because you have been treated before, you do not need to take a full course of medication this time.

The patient is diagnosed with vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to best prevent transmission of the infection to others? Droplet precautions Contact precautions Airborne precautions Standard precautions

The triage nurse at an ambulatory clinic receives a call from an individual with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this possible eye injury? "Remove any visible metal fragments." "Apply a loose dressing over your eyes." "Rinse your eyes immediately with water." "Keep your eyes open to allow tears to form."

When assessing the fetal heart rate (FHR) of a woman at 30 weeks of gestation, the nurse counts a rate of 82 beats/min. Initially the nurse should: recognize that the rate is within normal limits and record it. assess the woman's radial pulse. notify the physician. allow the woman to hear the heartbeat.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: decreased activity level. increased respiratory rate. hyperglycemia. shivering.

When examining the patient's ear with an otoscope, the nurse observes discharge in the canal and the patient reports pain with the examination. What should the nurse next assess the patient for? Sebaceous cyst Swimmer's ear Metabolic disorder Serous otitis media

When providing care to a young single woman just diagnosed with acute pelvic inflammatory disease, the nurse should: point out that inappropriate sexual behavior caused the infection. position the woman in a semi-Fowler position. explain to the woman that infertility is a likely outcome of this type of infection. tell her that antibiotics need to be taken until pelvic pain is relieved.

When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."

When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? Swimmer's ear Acute otitis media Impacted cerumen Chronic otitis media

Which action of a breastfeeding mother indicates the need for further instruction? Holds breast with four fingers along bottom and thumb at top. Leans forward to bring breast toward the baby. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth. Puts her finger into newborn's mouth before removing breast.

Which characteristic is associated with false labor contractions? Painless Decrease in intensity with ambulation Regular pattern of frequency established Progressive in terms of intensity and duration

Which description of postpartum restoration or healing times is accurate? The cervix shortens, becomes firm, and returns to form within a month postpartum. Rugae reappear within 3 to 4 weeks. Most episiotomies heal within a week. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

Which focused assessments would have priority in the care of a patient recently started on parenteral nutrition (PN)? Skin integrity and skin turgor Electrolyte levels and daily weights Auscultation of lung and bowel sounds Peripheral edema and level of consciousness

A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which nursing interventions should be included in the patient's plan of care (select all that apply.)? Initiate contact isolation precautions. Place the patient on a clear liquid diet. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns. Use hand sanitizer before and after patient or bodily fluid contact.

a, c, d

The nurse is teaching a family about sensory alterations. The nurse needs to provide additional teaching if a family member makes which statement? "I am going to wear earplugs when I mow the lawn." "If I stop smoking, I might enjoy eating more!" "So grandpa's stroke is why he thinks his left arm and leg aren't there any more." "My cousin has autism, and I am going to hug him more so he understands how much I care."

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? Fluid movement from the blood vessels into the cells Fluid movement from the interstitial spaces into the cells Fluid movement from the blood vessels into interstitial spaces Fluid movement from the interstitial space into the blood vessels

When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? 60 mL in 90 minutes 1200 mL in 24 hours 300 mL per 8-hour shift 20 mL for 2 consecutive hours

When weighing a newborn, the nurse should: leave its diaper on for comfort. place a sterile scale paper on the scale for infection control. keep hand on the newborn's abdomen for safety. weigh the newborn at the same time each day for accuracy.

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? IV tobramycin Incompatible blood transfusion Poststreptococcal glomerulonephritis Dissecting abdominal aortic aneurysm

Which patient has the morbidity risk? Male 6 ft, 1 in. tall; BMI 29 kg/m2 Female 5 ft, 6 in. tall; weight 150 lb Male with waist circumference 46 in Female 5 ft, 10 in. tall; obesity class III

Which patient is at risk for developing graft-versus-host disease (GVHD)? A 65-yr-old man who received an autologous blood transfusion A 40-yr-old man who received a kidney transplant from a living donor A 65-yr-old woman who received a pancreas and kidney from a deceased donor A 40-yr-old woman who received a bone marrow transplant from a close relative

Which patient is at risk for developing metabolic syndrome? A 62-yr-old white man who has coronary artery disease with chronic stable angina A 54-yr-old Hispanic woman who is sedentary and has nephrogenic diabetes insipidus A 27-yr-old Asian American woman who has preeclampsia and gestational diabetes mellitus A 38-yr-old Native American man who has diabetes mellitus and elevated hemoglobin A1C

Which statement by a military veteran being treated for posttraumatic stress disorder (PTSD) is the strongest evidence that the condition is being managed? a. "My mother said that I am much more like my old self." b. "I hope my buddies get the type of professional help I'm getting." c. "I didn't think my nightmares would ever stop but now I'm not so sure." d. "My children and I went to the fireworks display and we all really enjoyed it."

Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications? "My drug dosages will be lower because the medications enhance each other." "Taking more than one medication will put me at risk for developing allergies." "I will be more prone to malignancies because I will be taking more than one drug." "The lower doses of my medications can prevent rejection and minimize the side effects."

Which statement regarding infant weaning is correct? Weaning should proceed from breast to bottle to cup. The feeding of most interest should be eliminated first. Abrupt weaning is easier than gradual weaning. Weaning can be mother or infant initiated.

While summarizing teaching regarding genital herpes, which patient statement indicates a need for further instruction? "No cure is available for my genital herpes." "I will utilize my medication when I begin to have symptoms." "Genital herpes may be caused by herpes simplex virus type 1 or 2" "I am not able to infect a sexual partner unless I have active lesions."

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as metabolic acidosis. respiratory acidosis. respiratory alkalosis. within normal limits.

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Magnesium rising to 2.9 mg/dL Phosphorus falling to 2.1 mg/dL

You are the nurse admitting a patient with a diagnosis of Chronic Kidney Disease (CKD). Which order should you question? a) 2 gram sodium diet b) O2 via nasal cannula (NC) @ 4L/min c) Lasix 40 mg po twice a day d) IV 0.9% normal saline @ 125cc/hr

he nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates increased respirations. rapid pulse rate. red, sweaty skin. slow capillary refill.

he nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is: severe postpartum headache. limited perception of bladder fullness. increase in respiratory rate. hypotension.

The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action? Wear a mask to prevent transmission of infection. Wipe equipment with ammonia-based disinfectant. Instruct visitors to use the alcohol-based hand sanitizer. Don gloves and gown before entering the patient's room.

What is #1 cause of intra-renal AKI?

acute tubular necrosis

Where is fundus in the first 24 hours after birth?

at or below umbilicus

A 71-yr-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? "Do you feel like you have a fever?" "What time did you take the medication?" "Have you tried to commit suicide before?" "Are you experiencing any abdominal pain?

A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? Instruction on irrigating a colostomy Administration of a cleansing enema A high-fiber diet the day before surgery Administration of IV antibiotics for bowel preparation

A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? Notify the physician. Auscultate for bowel sounds. Reposition the tube and check for placement. Remove the tube and replace it with a new one.

After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate? Return the patient to NPO status. Place cool compresses on the abdomen. Encourage the patient to ambulate as ordered. Administer an as-needed dose of IV morphine sulfate.

An 18-yr-old young woman has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention? Induced vomiting Whole-bowel irrigation Administration of activated charcoal Administration of fresh frozen plasma

Students are having an end of the semester party, which includes drinking alcohol, having snacks, and swimming. A student was found floating in the pool. Which action by first responders is most important? Immobilizing the cervical spine Evacuating water from the lungs Securing the airway and providing ventilation Establishing IV access and infusing warmed fluids

The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors? a. Moving to a new community b. Starting a new job c. Becoming pregnant d. The death of a grandfather

The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? Low-pitched and rumbling above the area of obstruction High-pitched and hypoactive below the area of obstruction Low-pitched and hyperactive below the area of obstruction High-pitched and hyperactive above the area of obstruction

The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication? Take a dose of mineral oil at the same time. Add extra salt to food on at least one meal tray. Ensure a dietary intake of 10 g of fiber each day. Take each dose with a full glass of water or other liquid.

The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse? "It will increase bulk in the stool." "It will lubricate the intestinal tract to soften feces." "It will increase fluid retention in the intestinal tract." "It will increase peristalsis by stimulating nerves in the colon wall."

What is RIFLE

Risk, injury, failure, loss, end stage kidney disease

During a client's physical examination, the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as the: Hegar sign. McDonald sign. Chadwick sign. Goodell sign.

What is the priority nursing intervention in supporting the therapeutic management of a child with acute kidney injury? a) measuring daily weights b) monitoring oral intake c) providing sodium replacements d) monitoring for hypokalemia signs and symptoms

Eight months after the delivery of her first child, a 31-yr-old woman sought care for occasional incontinence when sneezing or laughing. Which measure should the nurse recommend first? Kegel exercises Use of adult incontinence pads Intermittent self-catheterization Dietary changes including fluid restriction

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? The fetal presenting part is 1 cm above the ischial spines. Effacement is 4 cm from completion. Dilation is 50% completed. The fetus has achieved passage through the ischial spines.

A nurse was accidently stuck with a needle used on a patient who is infected with human immunodeficiency virus (HIV). After reporting the incident, what care should this nurse first receive? Personal protective equipment Combination antiretroviral therapy Counseling to report blood exposures A negative evaluation by the manager

A 78-yr-old patient has stage 3 CKD and is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? Apple, green beans, and a roast beef sandwich Granola made with dried fruits, nuts, and seeds Watermelon and ice cream with chocolate sauce Bran cereal with ½ banana and milk and orange juice

A college student reports eye pain after studying for finals. What assessment should the nurse make first in determining the possible etiology of this eye pain? Do you wear contacts? Do you have any allergies? Do you have double vision? Describe the change in your vision.

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia? Stupor Erythema Increased anxiety Rapid respirations

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: vision. hearing. smell. taste.

A patient comes to the clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the patient for what characteristic finding of syphilis in the primary clinical stage? Chancre Alopecia Condylomata lata Regional adenopathy

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? Talks and coos to her son Seldom makes eye contact with her son Cuddles her son close to her Tells visitors how well her son is feeding

Parents can facilitate the adjustment of their other children to a new baby by: having the children choose or make a gift to give to the new baby on its arrival home. emphasizing activities that keep the new baby and other children together. having the mother carry the new baby into the home so she can show him or her to the other children. reducing stress on other children by limiting their involvement in the care of the new baby.

A patient has acquired immunodeficiency syndrome (AIDS) and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study result? The patient has the virus present and can transmit the infection to others. The patient is not able to transmit the virus to others through sexual contact. The patient will be prescribed lower doses of antiretroviral medications for 2 months. The syndrome has been cured, and the patient will be able to discontinue all medications.

A patient has been diagnosed with human immunodeficiency virus (HIV) infection. What rationale for taking more than one antiretroviral medication should the nurse give to the patient to improve compliance? Viral replication will be inhibited. They will decrease CD4+ T cell counts. It will prevent interaction with other drugs. More than one drug has a better chance of curing HIV.

The CDC-recommended medication for the treatment of chlamydia would be: doxycycline. podofilox. acyclovir. penicillin.

A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? Lethargy and constipation from hypercalcemia Positive Trousseau's sign from hypercalcemia Lethargy and constipation from hypocalcemia Positive Trousseau's sign from hypocalcemia

A patient is admitted with metabolic acidosis. Which system is not functioning normally? Renal system Buffer system Endocrine system Respiratory system

A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? Hearing loss Exophthalmos Conjunctivitis Recurrent fever

The ability to receive and interpret stimuli has nursing implications that are a priority in what human need? Safety Socialization Nutrition Mobility

How long is bottle feeding only?

0-6 months

How many cm does fundal height decrease per day?

A patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? Eat a light meal before the procedure. Avoid carbonated beverages before the procedure. Take nothing by mouth for 3 hours before the procedure. No special dietary restrictions are needed until after the procedure.

A patient who is infected with human immunodeficiency virus (HIV) is being taught by the nurse about health promotion activities such as good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? Delaying disease progression Preventing disease transmission Helping to cure the HIV infection Enabling an increase in self-care activities

What are normal magnesium level?

1.5-2.5

What is normal HR for newborn?

110-160

What is normal female HGB?

12-16

What are normal sodium levels?

135-145

What is desired BMI for adults?

18.5-24.9

How often do you have appointment during pregnancy for weeks 28-36?

When does alba occur?

2-6 weeks after birth

A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members? Core rewarming with warm fluids Ambulation to increase metabolism Frequent oral temperature assessment Gastric tube feedings to increase fluids

The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: wear a snug, supportive bra. allow warm water to soothe the breasts during a shower. express milk from breasts occasionally to relieve discomfort. place absorbent pads with plastic liners into her bra to absorb leakage.

A patient with systemic lupus erythematosus is receiving plasmapheresis to treat an acute attack. What symptoms will the nurse monitor to determine if the patient develops complications related to the procedure? Hypotension, paresthesias, and dizziness Polyuria, decreased reflexes, and lethargy Intense thirst, flushed skin, and weight gain Abdominal cramping, diarrhea, and leg weakness

A patient with type 2 diabetes is reporting a second urinary tract infections(UTI)within the past month. Which medication should the nurse expect to be ordered for the recurrent infection? Ciprofloxacin Fosfomycin Nitrofurantoin Trimethoprim-sulfamethoxazole

A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse would be most concerned regarding what this woman consumes during and after tennis matches. Which is the MOST important? Several glasses of fluid Extra protein sources, such as peanut butter Salty foods to replace lost sodium Easily digested sources of carbohydrat

A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a: primipara. primigravida. multipara. nulligravida.

What are normal phosphate levels?

2.4-4.4

When does symptomatic HIV count occur?

200-500 cells

When should newborn have first void?

24 hours

When should newborn have first poop?

24-48 hours

How many vessels does the newborn cord have?

A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system

3-1-0-1-0

When is the embryo?

3-8th week

A young male patient is seeking treatment for recurrence of genital tingling, burning, and itching. The nurse will expect a prescription for which class of medications? Antivirals Antibiotics Vaccination Contraceptives

An older adult patient is brought to the primary health care provider by an adult child reporting confusion. What testing should the nurse anticipate obtaining from this patient? Urinalysis Sputum culture Red blood cell count White blood cell count

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1-day postpartum. Expected findings include: little if any change leakage of milk at let-down swollen, warm, and tender on palpation a few blisters and a bruise on each areola small amount of clear, yellow fluid expressed

What are normal potassium levels?

3.5-5.0

What is normal urine output?

30 ml/hr

What is normal RR for newborn?

30-60

What is normal HCT?

36-46%

How often do you have appointment during pregnancy for first 2 trimesters?

4 weeks

A pregnant woman is the mother of two children. Her first pregnancy ended in a still birth at 32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the 5-digit system to describe this woman's current obstetric history, the nurse would record

4-1-2-0-2

When does serosa occur?

4-14 after birth

Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth? 1 hour 30 minutes 2 hours 4 hours

A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? D5W 0.9% saline Packed red blood cells Lactated Ringer's solution

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: are benign if they disappear within 48 hours of birth result from increased blood volume should always be further investigated usually occur with forceps delivery

A 50-yr-old African American woman has a body mass index (BMI) of 35 kg/m2, type 2 diabetes mellitus, hypercholesterolemia, and irritable bowel syndrome (IBS). She is seeking assistance in losing weight because, "I have trouble stopping eating when I should, but I do not want to have bariatric surgery." Which drug therapy should the nurse question if it is prescribed for this patient? Orlistat (Xenical) Lorcaserin (Belviq) Phentermine (Adipex-P) Phentermine and topiramate (Qsymia)

What is the desired BMI range for children in percentage?

5-85

In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth:

50-60

What CD4 count do immune problems start with HIV?

500

When are foods introduced to baby?

6 months

What is normal BP for newborn?

60-80/40-50

What are normal calcium levels?

8.6-10.2

What is normal range of CD4 T-cells?

800-1200 cells

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.

When is the fetus?

9-birth

1. What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? Apical heart rate of 90 beats/min, slightly irregular, when awake and active Acrocyanosis Harlequin color sign Weight loss representing 5% of the newborn's birth weight

8. An older adult patient states they don't seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? Look for cerumen in the ear. Assess for increased hair growth in the ear. Tell the patient it is probably related to aging. Ask the patient if he has fallen because of dizziness.

A 21-yr-old female patient came to the clinic for instruction to prevent recurrence of urinary tract infections. Which patient statement indicates that teaching was effective? "I will urinate before and after having intercourse." "I will use vinegar as a vaginal douche every week." "I should drink three 8-oz glasses of water daily." "I can stop the antibiotics when symptoms disappear."

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct? A common practice among Mexican women is known as los dos. Muslim cultures do not encourage breastfeeding due to modesty concerns. Latino women born in the United States are more likely to breastfeed. East Indian and Arab women believe that cold foods are best for a new mother.

The newborn passed her first stool 12 hours after delivery, which was dark green and sticky. Her parents are concerned and ask if she is constipated. Which of the following is an appropriate response to the parents' concerns? A. This is a normal newborn's first stool, called meconium. B. The newborn's first stool should be yellowish brown and nonsticky. C. The newborn may have a bowel obstruction. D. The newborn will be observed for signs of infection

The nurse cares for a 34-yr-old woman after bariatric surgery. The nurse determines that discharge teaching related to diet is successful if the patient makes which statement? "A high-protein diet that is low in carbohydrates and fat will prevent diarrhea." "Food should be high in fiber to prevent constipation from the pain medication." "Three meals a day with no snacks between meals will provide optimal nutrition." "Fluid intake should be at least 2000 mL per day with meals to avoid dehydration."

The nurse counsels a 64-yr-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the patient avoid? Venison, crab, and liver Spinach, cabbage, and tea Milk, yogurt, and dried fruit Asparagus, lentils, and chocolate

The nurse instructs an obese 22-yr-old man with a sedentary job about the health benefits of an exercise program. The nurse evaluates that teaching is effective when the patient makes which statement? "The goal is to walk at least 10,000 steps every day of the week." "Weekend aerobics for 2 hours is better than exercising every day." "Aerobic exercise will increase my appetite and result in weight gain." "Exercise causes weight loss by decreasing my resting metabolic rate."

The nurse is assessing an older adult patient. What type of age related disorders should the nurse assess for related to the increased immunologic response? Autoimmune response Cell-mediated immunity Hypersensitivity response Humoral immune response

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? Vitamin B12 Vitamin C Vitamin D Omega-3 fatty acids

The nurse is caring for a patient who is 5'6" tall and weighs 186 lb. The nurse has discussed reasonable weight loss goals and a low-calorie diet with the patient. Which statement made by the patient indicates a need for further teaching? "I will limit intake to 500 calories a day." "I will try to eat very slowly during mealtimes." "I'll try to pick foods from all of the basic food groups." "It's important for me to begin a regular exercise program."

The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? Discard all opened or used lens care products. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.

The nurse is surveying the assisted living facility regarding safety features for patients with sensory deficits. Which are the most appropriate accommodations? Fire and smoke alarms with both sound and flashing lights Colorful throw rugs to designate the purpose of various rooms Alarms on all exit doors Steps painted with dark colors

The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: progressive uterine contractions with cervical change. lightening. rupture of membranes. passage of the mucous plug (operculum).

The nurse taught new parents the guidelines to follow regarding the bottle-feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they: wash the top of the can and can opener with soap and water before opening the can. adjust the amount of water added according to the weight gain pattern of the newborn. add some honey to sweeten the formula and make it more appealing to a fussy newborn. warm formula in a microwave oven for a couple of minutes before feeding.

The nurse teaches a 50-yr-old woman who has a body mass index (BMI) of 39 kg/m2 about weight loss. Which dietary change would be most appropriate to recommend? Decrease fat intake and control portion size. Increase vegetables and decrease fluid intake. Increase protein intake and avoid carbohydrates. Decrease complex carbohydrates and limit fiber.

The nurse teaches the staff ensuring that standard precautions should be used when providing care for which type of patient? All patients regardless of diagnosis Pediatric and gerontologic patients Patients who are immunocompromised Patients with a history of infectious diseases

The patient reports a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? Amsler grid test B-scan ultrasonography Fluorescein angiography Intraocular pressure testing with Tono-Pen

What is the nurse's priority when changing the appliance for a patient with an ileal conduit? Keep the skin free of urine. Inspect the peristomal area. Cleanse and dry the area gently. Affix the appliance to the faceplate.

With regard to medications, herbs, shots, and other substances normally encountered, the maternity nurse should be aware that: prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus. the greatest danger of drug-caused developmental deficits in the fetus is seen in the final trimester. killed-virus vaccines (e.g., tetanus) should not be given during pregnancy, but live-virus vaccines (e.g., measles) are permissible. no convincing evidence exists that secondhand smoke is potentially dangerous to the fetus.

With regard to protein in the diet of pregnant women, nurses should be aware that: many protein-rich foods are also good sources of calcium, iron, and b vitamins. many women need to increase their protein intake during pregnancy. as with carbohydrates and fat, no specific recommendations exist for the amount of protein in the diet. high-protein supplements can be used without risk by women on macrobiotic diets.

With regard to umbilical cord care, nurses should be aware that: the stump can easily become infected. a nurse noting bleeding from the vessels of the cord should immediately call for assistance. the cord clamp is removed at cord separation. the average cord separation time is 5 to 7 days.

he birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should: encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs. suggest that the mother switch to bottle-feeding since the breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. notify the physician since the newborn is being poorly nourished. refer the mother to a lactation consultant to improve her breastfeeding technique.

Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? (Select all that apply.) Postural hypotension Temperature of 100.4° F Bradycardia—pulse rate of 55 beats/min Pain in left calf with dorsiflexion of left foot Lochia rubra with foul odor

D, E

For the labor nurse, care of the expectant mother begins with which situations? (Select all that apply.) The onset of progressive, regular contractions The bloody, or pink, show The spontaneous rupture of membranes Formulation of the woman's plan of care for labor Moderately painful contractions

A, B, C

Nurses can advise their patients that which of these signs precede labor? (Select all that apply.) A return of urinary frequency as a result of increased bladder pressure Persistent low backache from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions A decline in energy, as the body stores up for labor Uterus sinks downward and forward in first-time pregnancies.

A, B, C

What should the nurse teach the patients in the assisted living facility to decrease their risk for antibiotic-resistant infection (select all that apply.)? Wash hands frequently. Take antibiotics as prescribed. Take the antibiotic until it is gone. Take antibiotics to prevent illnesses like colds. Save leftover antibiotics to take if needed later.

A, B, C

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: (Select all that apply.) Prevent exposure to people with upper respiratory tract infections Keep the infant away from secondhand smoke Avoid loose bedding, waterbeds, and beanbag chairs Do not let the infant sleep on his or her back Keep a bulb suction available at home.

A, B, C, E

The nurse is developing a dietary teaching plan for a patient on a vegetarian diet. The nurse should provide the patient with which examples of protein containing foods? (Select all that apply.) Dried beans Seeds Peanut butter Bagel Eggs

A, B, C, E

Which suggestions should the nurse include when teaching about appropriate weight gain in pregnancy? (Select all that apply.) Underweight women should gain 12.5 to 18 kg. Obese women should gain at least 7 to 11.5 kg. Adolescents are encouraged to strive for weight gains at the upper end of the recommended scale. In twin gestations, the weight gain recommended for a single fetus pregnancy should simply be doubled. Normal weight women should gain 11.5 to 16 kg.

A, B, C, E

The nurse is caring for a bariatric surgery patient a few hours postoperatively. Which would be included in the nursing plan of care? (Select All That Apply) A. Monitor the abdominal incision frequently B. Teach the patient to cough and deep breathe C. Ensure the patient is NPO to prevent vomiting D. Apply sequential compression devices to both legs E. Provide pain medications as needed F. Maintain the head of bed to a maximum of 15 degrees

A, B, D, E

Which of these statements indicate the effect of breastfeeding on the family or society at large. (Select all that apply.) Breastfeeding requires fewer supplies and less cumbersome equipment. Breastfeeding saves families money. Breastfeeding costs employers in terms of time lost from work. Breastfeeding benefits the environment. Breastfeeding results in reduced annual health care costs.

A, B, D, E

Vaginal examinations should be performed by the nurse under which of these circumstances. (Select all that apply.) An admission to the hospital at the start of labor When accelerations of the fetal heart rate (FHR) are noted On maternal perception of perineal pressure or the urge to bear down When membranes rupture When bright, red bleeding is observed

A, C, D

Which statements about multifetal pregnancy are most appropriate? (Select all that apply.) The expectant mother often develops anemia because the fetuses have a greater demand for iron. Twin pregnancies come to term with the same frequency as single pregnancies. The mother should be counseled to increase her nutritional intake and gain more weight. Backache and varicose veins are often more pronounced. Spontaneous rupture of membranes before term is uncommon.

A, C, D

When working with parents who have some form of sensory impairment, nurses should consider which information when writing a plan of care? One of the major difficulties visually impaired parents experience is the skepticism of health care professionals Visually impaired mothers cannot overcome the infant's need for eye-to-eye contact The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information Childbirth education and other materials are available in Braille.

A, C, D, E

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: (Select all that apply.) passenger. placenta. passageway. psychologic response. powers. position.

A, C, D, E, F

What should teaching for patients with a sexually transmitted infection (STI) include (select all that apply.)? Treatment of sexual partners Douching may help to provide relief of itching. Importance of retesting after treatment to confirm cure Cotton undergarments are preferred over synthetic materials. Sexual abstinence is indicated during the communicable phase of the disease. Condoms should be used during as well as after treatment during sexual activity.

A, C, D, E, F

When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply.)? Grapes Oranges Bananas Potatoes Tomatoes

A, C, D, e

The maternity nurse should notify the health care provider about which assessment findings during labor? (Select all that apply.) Positive urine drug screen Blood glucose level of 78 mg/dL Increased systolic blood pressure during first stage Elevated white blood cell count Oral temperature of 99.8° F Respiratory rate of 10 breaths/min

A, C, F

A community health nurse is conducting an initial assessment of a new patient. Which assessments should the nurse include when screening the patient for metabolic syndrome (select all that apply.)? Blood pressure Resting heart rate Physical endurance Waist circumference Fasting blood glucose

A, D, E

The patient has parenteral nutrition (PN) infusing with amino acids and dextrose. During shift change, the nurse reports the tubing, bag, and dressing were changed 20 hours ago. What care should the incoming nurse plan to deliver (select all that apply.)? Giving the patient insulin if needed Ensuring that the next bag has been ordered Checking amount of solution left in the bag Assessing the insertion site and change the tubing Verifying the accuracy of the new solution and ingredients

A, b, c, e

Appropriate approaches used by the long-term care nurse to provide education for a 73 year old who has just been diagnosed with diabetes include which of the following? (Select all that apply.) Schedule a visit by another resident who is diabetic. Demonstrate food choices using food photographs. Avoid discussion of the patient's favorite foods. Remind the patient that a lot of damage has already occurred. Encourage the patient's family to participate in teaching sessions. Ask the patient about past experiences with lifestyle changes.

A, b, e, f

he stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply.)? Administer bolus or continuous feedings. Evaluate the nutritional status of the patient. Administer medications through the gastrostomy tube. Monitor for complications related to the tube and enteral feeding. Teach the caregiver about feeding via the gastrostomy tube at home.

A, c

A dehydrated patient is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions (select all that apply.)? Lung sounds Bowel sounds Blood pressure Serum sodium level Serum potassium level

A, c, d

A malnourished patient has been diagnosed with protein deficiency. Which complications should the nurse anticipate (select all that apply.)? Edema Asthma Anemia Malabsorption syndrome Impaired wound healing Gastrointestinal bleeding

A, c, e

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.) Body mass index (BMI) of 17 Waist-to-hip ratio of 1.0 Weight loss of 6% since last month's visit Prealbumin level of 16 mg/dL Hematocrit level of 50% Hemoglobin level of 8.2 g/dL

A, c, f

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas with temperatures near 100°F (37.7°C) for the past 2 weeks. When assessing the patient, the nurse finds hypotension, body temperature of 104°F (40°C), dry and ashen skin, and neurologic symptoms. What treatments should the nurse anticipate (select all that apply.)? Administer 100% O2. Immerse in an ice bath. Administer cool IV fluids. Cover the patient to prevent chilling. Administer acetaminophen (Tylenol). Administer chlorpromazine for shivering.

A, c, f

2. You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply.)? The potassium level may be increased if the patient has nephropathy. The patient has been eating excessive amounts of foods that increase potassium levels. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A, d, e

The urinalysis of a patient reveals a high microorganism count. What data should the nurse use to determine which part of the urinary tract is infected (select all that apply.)? Pain location Fever and chills Mental confusion Urinary hesitancy Urethral discharge Postvoid dribbling

A, e

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)? Weakness Paresthesia Facial spasms Muscle tremors Depressed reflexes

A, e

The nurse is planning to teach a patient about possible enteral tube feedings. Which would be an advantage of using a thin, silicone feeding tube as compared to a more rigid feeding tube with a sump? The thin, silicone tube has: (Select All That Apply) A. Less risk of aspiration B. Less risk of nasal mucosal damage C. Less wait time until feedings are started D. Less likely to clog or kink E. Longer term feedings F. Less risk of peritonitis

A,B, E

A patient has a hemoglobin level of 8.2 gm/dL and hematocrit of 28%, and is receiving a transfusion of packed red blood cells. The patient reports back pain, chills, and has a fever during the transfusion. What is the priority nursing action? Call the physician Stop the transfusion Administer acetaminophen for the pain and fever Monitor the patient for the remainder of the transfusion

A parent does not want their child to have any extra immunizations for diseases that no longer occur. What teaching about immunization should the nurse provide this mother? There is currently no need for those older vaccines. There is a reemergence of some of the infections, such as pertussis. There is no longer an immunization available for some of those diseases. The only way to protect your child is to have the federally required vaccines.

A patient admitted to the emergency department after a motor vehicle accident. Which urinalysis findings would the nurse expect if kidney trauma occurred (select all that apply.)? Casts Glucose Bilirubin Myoglobinuria Red blood cells White blood cells

D, e

A patient complains of intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? "Do you take ginkgo to treat asthma or tinnitus?" "What do you take if you have allergy symptoms?" "Are you taking propranolol for an anxiety disorder?" "How long have you been taking prednisone (Deltasone)?"

What is rom birth to the mother's return to pre-pregnancy (about 6 weeks)?

Postpartum

What are 5 Ps?

Powers, passengers, passage, position of mother, and psyche

A military veteran being treated for substance abuse shares that the family is experiencing financial problems since being discharged. In order to assess the individual's coping skills, the nurse asks: a. "Do you have any idea about how your finances got out of your control?" b. "How well were you at managing your finances before leaving the military?" c. "Can you give me some idea of the kind of financial help you feel you need?" d. "Have your financial expenses increased dramatically since being discharged?"

A nurse is admitting a patient with advanced renal carcinoma. Which clinical manifestations represent the "classic triad" observed in patients with renal cancer? Fever, chills, and flank pain Hematuria, flank pain, and palpable mass Hematuria, proteinuria, and palpable mass Flank pain, palpable abdominal mass, and proteinuria

A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. What is most important for the nurse to include in the plan of care? a. Medication to calm the perpetrator of the violence b. A list of community resources c. A referral for self-defense training d. A referral to the victim's religious advisor

. What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." "I will not have a menstrual cycle for 6 months after childbirth." "My first menstrual cycle will be heavier than normal and then will be light for several months after."

6. With regard to the diagnosis and management of amenorrhea, nurses should be aware that: it probably is the result of a hormone deficiency that can be treated with medication. it may be caused by stress or excessive exercise or both. it likely will require the client to eat less and exercise more. it often goes away on its own.

A 22-yr-old man is being treated at a college health care clinic for gonorrhea. What should the nurse include in patient teaching? "While being treated for the infection, you will not be able to pass this infection on to your sexual partner." "While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol." "It's important to complete your full course of antibiotics in order to ensure that you become resistant to reinfection." "The symptoms of gonorrhea will resolve on their own, but it is important for you to abstain from sexual activity while this is occurring.

A 22-yr-old patient's blood pressure during a pre-employment physical examination was 110/68 mm Hg. During a health fair 2 months later, the blood pressure is 154/96 mm Hg. What renal problem could contribute to this rise in blood pressure? Renal trauma Renal artery stenosis Renal vein thrombosis Benign nephrosclerosis

A 52-yr-old man with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective? Negative bacterial culture Absence of genital lesions Reduction of genital warts No drainage from chancre sore

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action? Places a hypothermia blanket at the bedside Adjusts the bed to the Trendelenburg position Obtains electronic equipment for monitoring the vital signs Secures a pump to administer the ordered intravenous fluids

A frail older adult with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. Which foods would the nurse suggest for breakfast? Orange juice and dry toast Oatmeal with butter and cream Waffles with fresh strawberries Banana and unsweetened yogurt

A healthy older adult patient requests a "flu shot" during an office visit. When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply.)? Shingles Pneumonia Meningococcal Haemophilus influenzae type b (Hib) Measles, mumps, and rubella (MMR)

A nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates an understanding of the nurse's instructions if she states that a positive sign of pregnancy is: a positive pregnancy test. fetal movement palpated by the nurse-midwife. Braxton Hicks contractions. quickening.

A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect to see in this patient? Redness and swelling of the conjunctiva Drooping of the upper lid margin in one or both eyes Redness, swelling, and crusting along the eyelid margins Small, superficial white nodules along the eyelid margin

A patient is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient? Muscle weakness Cardiac dysrhythmias Increased urine output Anemia and leukopenia

A patient is being admitted with anorexia nervosa. Which clinical manifestations should the nurse anticipate? Sensitivity to heat, fatigue, and polycythemia Hair loss; dry, yellowish skin; and constipation Tented skin turgor, hyperactive reflexes, and diarrhea Dysmenorrhea, hypoactive bowel sounds, and hunger

A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? Photorefractive keratectomy (PRK) Phakic intraocular lenses (phakic IOLs) Refractive intraocular lens (refractive IOL) Laser-assisted in situ keratomileusis (LASIK)

A patient waiting for a kidney transplant asks the nurse to explain the difference between a negative and positive crossmatch. Which statement by the nurse would be the most accurate response? "A negative crossmatch means that both the donor and recipient are Rh negative, and the transplant is safe." "A negative crossmatch means that no preformed antibodies are present and the transplant would be safe." "A positive crossmatch means the blood type is the same between donor and recipient, and the transplant is safe." "A positive crossmatch means that both the donor and the recipient have antigens that are similar, and the transplant would be safe."

A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? 0.9% sodium chloride 25% albumin solution Lactated Ringer's solution 5% dextrose in 0.45% saline

A patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse? Blood glucose level of 125 mg/dL Serum phosphate level of 1.9 mg/dL White blood cell count of 10,500/µL Serum potassium level of 4.6 mEq/L

A patient who cannot afford enough food for her family states she only eats after her children have eaten. At a clinic visit, she reports bleeding gums; loose teeth; and dry, itchy skin. Which vitamin deficiency would the nurse suspect? Folic acid Vitamin C Vitamin D Vitamin K

A patient who has sustained severe burns in a motor vehicle accident is starting parenteral nutrition (PN). Which principle should guide the nurse's administration of PN? Administration of PN requires clean technique. Central PN requires rapid dilution in a large volume of blood. Peripheral PN delivery is preferred over the use of a central line. Only water-soluble medications may be added to the PN by the nurse.

A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks being experienced. What should the nurse include in the discharge teaching for this patient? Airplane travel will be more comfortable now. Avoid sudden head movements or position changes. Cough or blow the nose to keep the Eustachian tubes clear. Take antihistamines, antiemetics, and sedatives for recovery.

A pregnant woman at 7 weeks of gestation complains to her nurse midwife about frequent episodes of nausea during the day with occasional vomiting. She asks what she can do to feel better. The nurse midwife could suggest that the woman: drink warm fluids with each of her meals. eat a high-protein snack before going to bed. keep crackers and peanut butter at her bedside to eat in the morning before getting out of bed. schedule three meals and one midafternoon snack a day.

A pregnant woman experiencing nausea and vomiting should: drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning. eat small, frequent meals (every 2 to 3 hours). increase her intake of high-fat foods to keep the stomach full and coated. limit fluid intake throughout the day.

A pregnant woman with a body mass index (BMI) of 22 asks the nurse how she should be gaining weight during pregnancy. The nurse's BEST response would be to tell the woman that her pattern of weight gain should be approximately: a pound a week throughout pregnancy. 2 to 5 lbs during the first trimester, then a pound each week until the end of pregnancy. a pound a week during the first two trimesters, then 2 lbs per week during the third trimester. a total of 25 to 35 lbs.

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: instill within 15 minutes of birth for maximum effectiveness. cleanse eyes from inner to outer canthus before administration. apply directly over the cornea. flush eyes 10 minutes after instillation to reduce irritation.

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should: foster an active role in the baby's care. provide time for the mother to reflect on the events of and her behavior during childbirth. recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. promote maternal independence by encouraging her to meet her own hygiene and comfort needs.

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: urinary tract infection. excessive uterine bleeding. a ruptured bladder. bladder wall atony.

A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be: constipation. alteration in the pattern of fetal movement. heart palpitations. edema in the ankles and feet at the end of the day.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: "Don't worry about it. You'll do fine." "It's normal to be anxious about labor. Let's discuss what makes you afraid." "Labor is scary to think about, but the actual experience isn't." "You may have an epidural. You won't feel anything."

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. alerts the physician that the infant has a dislocated hip. informs the parents and physician that molding has not taken place. suggests that if the condition does not change, surgery to correct vision problems might be needed.

Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester? Less audible heart sounds (S1, S2) Increased pulse rate Increased blood pressure Decreased red blood cell (RBC) production

Concerning the third stage of labor, nurses should be aware that: the placenta eventually detaches itself from a flaccid uterus the duration of the third stage may be as short as 3 to 5 minutes it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface the major risk for women during the third stage is a rapid heart rate

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to: apply topical anesthetics with each diaper change. expect a yellowish exudate to cover the glans after the first 24 hours. change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. apply constant pressure to the site if bleeding occurs and call the physician.

If exhibited by an expectant father, what would be a warning sign of ineffective adaptation to his partner's first pregnancy? Views pregnancy with pride as a confirmation of his virility Consistently changes the subject when the topic of the fetus/newborn is raised Expresses concern that he might faint at the birth of his baby Experiences nausea and fatigue, along with his partner, during the first trimester

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior? The parents have difficulty naming the infant. The parents hover around the infant, directing attention to and pointing at the infant. The parents make no effort to interpret the actions or needs of the infant. The parents do not move from fingertip touch to palmar contact and holding.

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Lull: no contractions; dilation stable; duration of 20 to 60 minutes Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? (Select all that apply.) Newborn turns head toward stimulus when eliciting rooting reflex. Newborn's fingers fan out when palmar reflex checked. Newborn forces tongue outward when tongue touched. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.

The nurse administers a Gardasil vaccine to an 18-yr-old female patient. After the injection, which patient instruction is priority? Avoid sexual activity for 24 to 48 hours. Remain lying down for at least 15 minutes. Return to the clinic in 6 months for a second dose. Use two methods of birth control to avoid pregnancy.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: place her on a bedpan to empty her bladder. massage her fundus. call the physician. administer Methergine, 0.2 mg IM, which has been ordered prn.

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: tonic neck reflex. Moro reflex. cremasteric reflex. Babinski reflex.

The nurse has completed initial instruction with a patient regarding a weight loss program. The nurse determines that the teaching has been effective when the patient makes which statement? "I plan to lose 4 lb a week until I have lost the 60-lb goal." "I will keep a diary of weekly weights to illustrate my weight loss." "I will restrict my carbohydrate intake to less than 30 g/day to maximize weight loss." "I should not exercise more than my program requires because increased activity increases the appetite."

The nurse has experienced a recent increase in the incidence of hospital care-associated infections (HAIs) on the unit. Which nursing action should be prioritized in the response to this trend? Use of gloves during patient contact Frequent and thorough hand washing Prophylactic, broad-spectrum antibiotics Fitting and appropriate use of N95 masks

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: telling the mother not to worry since all breastfed babies have this type of stool. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. asking the mother what she ate at her last meal. suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A Caucasian female who is 39 weeks gestation An African-American female who is breastfeeding An Asian female diagnosed with hypoglycemia A Hispanic female who has a BMI of 24.1

The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? Hypothyroidism and polycythemia Hypertension and diabetes mellitus Atrial fibrillation and atherosclerosis Vascular dementia and chronic fatigue

The nurse is caring for a 45-yr-old woman with a herniated lumbar disc. The patient realizes that weight loss is necessary to lessen back strain. The patient is 5'6" tall and weighs 186 lb (84.5 kg) with a body mass index (BMI) of 28 kg/m2. The nurse explains this measurement places her in which weight category? Obese Overweight Severely obese Normal weight

The nurse is caring for a 62-yr-old woman taking tolterodine (Detrol) to treat urinary urgency and incontinence. Which instruction should be included in the discharge plan? "Stop smoking for 2 to 3 weeks before starting to take this medication." "Suck on sugarless candy or chew sugarless gum if you develop a dry mouth." "Have your vision checked every 6 months because this drug can cause cataracts." "Ask your physician to prescribe an extended-release form if you have loose stools."

The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is malted milk. orange juice. tomato juice. hot chocolate.

The nurse is caring for a patient newly diagnosed with human immunodeficiency virus (HIV). What does the nurse explain to the patient the criteria for diagnosis is based on? Presence of HIV antibodies CD4+ T cell count below 200/µL Presence of oral hairy leukoplakia White blood cell count below 5000/µL

The nurse is caring for a patient with a nephrostomy tube. The tube has stopped draining. After receiving orders, what should the nurse do? Keep the patient on bed rest. Use 5 mL of sterile saline to irrigate. Use 30 mL of water to gently irrigate. Have the patient turn from side to side.

The nurse is evaluating the nutritional status of a patient undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would best indicate the patient has protein-calorie malnutrition (PCM)? Serum transferrin Serum prealbumin C-reactive protein (CRP) Alanine transaminase (ALT)

The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates resolution of the middle ear infection? Fenestrations are visible in the tympanic membrane. Tympanic membrane is gray, shiny, and translucent. Cone of light is not visible on the tympanic membrane. Tympanic membrane is blue and bulging with no landmarks.

The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? "This is often due to an infection that will resolve on its own." "Many people experience an age-related decline in their hearing." "This is likely an effect of your medications. Try stopping them for a few days." "You can likely accommodate for your hearing loss with a few small changes in your routine."

The nurse is teaching a group of young adults who live in a dormitory about the prevention of antibiotic-resistant infections. What should be included in the teaching plan? Save leftover antibiotics for future uses. Hand washing can prevent many infections. Antibiotics are indicated for preventing most colds. Stop taking prescribed antibiotics when symptoms improve.

The nurse is teaching a patient with type 1 diabetes mellitus who had surgery to revise a lower leg stump with a skin graft about nutrition. What food should the nurse teach the patient to eat to best facilitate healing? Nonfat milk Chicken breast Fortified oatmeal Olive oil and nuts

Which nursing intervention is most appropriate in providing care for an adult patient with newly diagnosed adult onset polycystic kidney disease (PKD)? Help the patient cope with the rapid progression of the disease. Suggest genetic counseling resources for the children of the patient. Expect the patient to have polyuria and poor concentration ability of the kidneys. Implement appropriate measures for the patient's deafness and blindness in addition to the renal problems.

Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? "You will need to get rid of your pets." "You should sleep in an air-conditioned room." "You would do best to stay indoors during the winter months." "You will need to dust your house with a dry feather duster twice a week."

Which test is performed to determine if membranes are ruptured? Urine analysis Fern test Leopold maneuvers Artificial Rupture of Membranes (AROM)

With regard to nutritional needs during lactation, a maternity nurse should be aware that: the mother's intake of vitamin C, zinc, and protein now can be lower than during pregnancy. caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful. critical iron and folic acid levels must be maintained. lactating women can go back to their prepregnant calorie intake.

With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is: an on-demand feeding schedule. breastfeeding. lower-calorie infant formula. smaller, more frequent feedings.

Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with: spina bifida. intrauterine growth restriction. diabetes mellitus. Down syndrome.

newborn male, estimated to be 39 weeks of gestation, would exhibit: extended posture when at rest. testes descended into scrotum. abundant lanugo over his entire body. ability to move his elbow past his sternum.

A patient is admitted to the emergency department (ED) with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing actions will help identify the need for further assessment of the cause of this patient's manifestations (select all that apply.)? Assessment of lung sounds Assessment of sexual behavior Assessment of living conditions Assessment of drug and syringe use Assessment of exposure to an ill person

B, D

8. Which of these statements are helpful and accurate nursing advice concerning bathing the new baby. (Select all that apply.) Newborns should be bathed every day, for the bonding as well as the cleaning Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Only plain warm water can be used to preserve the skin's acid mantle. Powders are not recommended because the infant can inhale powder. Bathe immediately after feeding while baby is calm and relaxed.

B, D

A person of Northern heritage is at an increased risk for which of the following? (Select all that apply.) Vitamin C deficiency Type 1 diabetes Celiac disease Type 2 diabetes Hypertension Metabolic syndrome

B, C

The maternity nurse promoting parental-infant attachment should incorporate which appropriate cultural beliefs into the plan of care? (Select all that apply.) Asian mothers are encouraged to return to work as soon as possible. Jordanian mothers have a 40-day lying-in after birth. Japanese mothers rest for the first 2 months after childbirth. Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake. Encourage Vietnamese mothers to cuddle with the newborn.

B, C

5. An acoustic neuroma is removed from a patient. The nurse instructs the patient about tumor recurrence. What should the nurse instruct the patient to monitor (select all that apply.)? Lack of coordination Episodes of dizziness Worsening of hearing Inability to close the eye Clear drainage from the nose

B, C D

A nurse counseling a client with endometriosis understands which statements regarding the management of endometriosis is accurate? (Select all that apply) Bone loss from hypoestrogenism is not reversible. Side effects from the steroid danazol include masculinizing traits. Surgical intervention often is needed for severe or acute symptoms. Women without pain and who do not want to become pregnant need no treatment. Women with mild pain who may want a future pregnancy may take nonsteroidal antiinflammatory drugs (NSAIDs).

B, C, D

Which nursing diagnoses for patients with sensory perceptual variances may be included in a plan of care? (Select all that apply.) Knowledge deficit for nutrition Risk for injury Impaired mobility Altered nutrition that is less than the body requirements Decreased cardiac output

B, C, D

he nurse is caring for a patient after bariatric surgery. What should be included in the plan of care (select all that apply.)? Teach the patient to increase carbohydrate intake. Assess for incisional pain versus anastomosis leak. Maintain elevation of the head of bed at 35-45 degrees. Monitor for vomiting that is a common complication. Instruct the patient to consume liquids frequently during meals. Assist with early independent ambulation during hospitalization.

B, C, D, F

When helping a woman cope with postpartum blues, the nurse should offer what appropriate suggestions? (Select all that apply.) The father should take over care of the baby, because postpartum blues are exclusively a female problem. Get plenty of rest. Plan to get out of the house occasionally. Asking for help will not foster independence. Use La Leche League or community mental health centers.

B, C, E

The nurse is setting up a new bariatric unit for surgical patients. Which equipment would be included for these patients? (Select All That Apply) A. Shorter intravenous catheters B. Incentive spirometers C. Larger blood pressure cuffs D. Wheel chairs with fixed arms E. Amplified stethoscopes F. Transfer devices

B, C, E, F

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)? Have patient restrict fluid intake to less than 2000 mL/day. Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake to 3000 to 4000 mL. Any heartburn can be managed with an as needed calcium-containing antacid.

B, C, d

The nurse should include which information when teaching a 15-year-old about genital tract infection prevention? (Select all that apply.) Wear nylon undergarments. Avoid tight-fitting jeans. Use floral scented bath salts. Decrease sugar intake. Do not douche. Limit time spent wearing a wet bathing suit.

B, D, E, F

After completing a postpartum assessment on woman who delivered 20 hours ago, the nurse should report which assessment findings to the health care provider? (Select all that apply.) Temperature 100.0° F Pulse 110 beats/min Respiratory rate 12 breaths/min Blood pressure 125/78 Temperature 38° C

B, E

What is assessed in postpartum?

Breasts, uterus, bowels, bladder, lochia, episiotomy/laceration/c section

. Otoscopic examination of the patient's left ear indicates the presence of an exostosis. What does the nurse prepare to teach the patient about regarding the growth? Surgery Electrocochleography Monitoring of the growth Irrigation of the ear canal

A 19-yr-old man comes to the outpatient clinic for treatment of uncomplicated gonorrhea. Which patient statement requires immediate clarification by the nurse? "I should avoid alcohol intake for at least 2 weeks." "I will have my sexual partner come in for treatment." "After I start the antibiotic, it is safe to have sex again." "After the treatment, I do not need to return to the clinic for retesting."

A 24-yr-old patient is at the clinic with symptoms of purulent vaginal discharge, dysuria, and dyspareunia. She is sexually active and has multiple partners. What should the nurse explain as the rationale for Chlamydia screening? Chlamydia is frequently comorbid with HIV. Chlamydial infections may progress to sepsis. Untreated chlamydial infections can lead to infertility. Chlamydial infections are treatable only in the early stages of infection.

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? Limit foods high in potassium Calcium gluconate IV piggyback Spironolactone (Aldactone) daily Administer intravenous insulin and glucose

A client has begun to view the nurse in a sexual context. The primary client-focused reason for informing the client that this is an inappropriate expression of sexual feelings is that the: nurse is at risk for being sued for professional misconduct. client will never redirect these feelings without extensive professional help. nurse can then assist the client in identifying the causes of the inappropriate feelings. client can then begin to transfer the sexual attention to a more appropriate individual.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

A newborn is placed under a radiant heat warmer. The nurse knows that thermoregulation presents a problem for newborns because: their renal function is not fully developed, and heat is lost in the urine. their small body surface area favors more rapid heat loss than does an adult's body. they have a relatively thin layer of subcutaneous fat that provides poor insulation. their normal flexed posture favors heat loss through perspiration.

A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action? Monitor the patient's fluid balance. Assess the patient's need for analgesia. Monitor for signs and symptoms of an adverse reaction. Assess the patient for changes in level of consciousness.

A patient has scleroderma and hypertension. The nurse knows this could be related to which renal diagnoses? Obstructive uropathy Goodpasture syndrome Chronic glomerulonephritis Calcium oxalate urinary calculi

A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? Use suitable coping strategies to reduce stress. Identify patient's strengths and support system. Verbalize feelings related to visual impairment. Transition successfully to the sudden vision loss.

A patient newly diagnosed with glaucoma asks the nurse what has made the pressure in the eyes so high. Which is the nurse's most accurate response? Back pressure from cardiac congestion causes corneal edema. Cerebral venous dilation prevents normal interstitial fluid resorption. Increased production of aqueous humor or blocked drainage increases pressure. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.

A patient received penicillin V potassium intramuscular (IM) causing a systemic anaphylactic reaction. What manifestations does the nurse observe initially? Dyspnea Dilated pupils Itching and edema Wheal-and-flare reaction

A patient voices an understanding of instructions about furosemide (Lasix) when he makes which statement? "I will report any blurred vision." "I expect that this will cause me to have increased sensitivity to saltiness." "If I notice ringing in my ears, I will call the doctor." "I know that I need to monitor my feet for possible skin changes."

A patient who has dysphagia after a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into the plan of care? Use 30 mL of normal saline to flush the tube every 4 hours. Avoid flushing the tube any time the patient is receiving continuous feedings. Flush the tube before and after feedings if the patient's feedings are intermittent. Flush the PEG with 100 mL of sterile water before and after medication administration.

A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? Vertigo Syncope Dizziness Nystagmus

A pregnant woman at 10 weeks of gestation jogs three or four times per week. She is concerned about the effect of exercise on the fetus. The nurse should inform her: "You don't need to modify your exercising any time during your pregnancy." "Stop exercising, because it will harm the fetus." "You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month." "Jogging is too hard on your joints; switch to walking now."

A pregnant woman demonstrates understanding of the nurse's instructions regarding relief of leg cramps if she: Wiggles and points her toes during the cramp. Applies cold compresses to the affected leg. Extends her leg and dorsiflexes her foot during the cramp. Avoids weight bearing on the affected leg during the cramp.

A pregnant woman who was tested and diagnosed with human immunodeficiency virus (HIV) infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? "The baby will probably be infected with HIV." "Only an abortion will keep your baby from having HIV." "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."

An effective relief measure for primary dysmenorrhea would be to: reduce physical activity level until menstruation ceases. begin taking prostaglandin synthesis inhibitors on the first day of the menstrual flow. decrease intake of salt and refined sugar about 1 week before menstruation is about to occur. use barrier methods rather than the oral contraceptive pill (OCP) for birth control.

When assessing an adult patient's external ear canal and tympanum, what assessment techniques should the nurse use? Ask the patient to tip his or her head toward the nurse. Identify a pearl gray tympanic membrane as a sign of infection. Gently pull the auricle up and backward to straighten the canal. Identify a normal light reflex by the appearance of irregular edges.

An expectant father confides in the nurse that his pregnant wife, 10 weeks of gestation, is driving him crazy. "One minute she seems happy, and the next minute she is crying over nothing at all. Is there something wrong with her?" The nurse's BEST response would be: "This is normal behavior and should begin to subside by the second trimester." "She may be having difficulty adjusting to pregnancy; I will refer her to a counselor that I know." "This is called emotional liability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant." "You seem impatient with her. Perhaps this is precipitating her behavior."

An older male patient visits his primary care provider because of burning on urination and production of foul-smelling urine. What contributing factor should the health care provider consider? High-purine diet Sedentary lifestyle Benign prostatic hyperplasia (BPH) Recent use of broad-spectrum antibiotics

During a health history, a 43-yr-old teacher complains of increasing difficulty reading printed materials for the past year. What change related to aging does the nurse suspect? Myopia Hyperopia Presbyopia Astigmatism

During the first trimester the pregnant woman would be most motivated to learn about: fetal development. impact of a new baby on family members. measures to reduce nausea and fatigue so she can feel better. location of childbirth preparation and breastfeeding classes.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? The healthy newborn should be taken to the nursery for a complete assessment. After drying, the infant should be given to the mother wrapped in a receiving blanket. Encourage skin-to-skin contact of mother and baby. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

Excessive blood loss after childbirth can have several causes; however, the most common is: vaginal or vulvar hematomas. unrepaired lacerations of the vagina or cervix. failure of the uterine muscle to contract firmly. retained placental fragments.

Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: return to prepregnant weight is usually achieved by the end of the postpartum period. fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-lb weight loss. the expected weight loss immediately after birth averages about 11 to 13 lbs. lactation will inhibit weight loss since caloric intake must increase to support milk production.

In developing a weight reduction program with a 45-yr-old female patient who weighs 197 lb, the nurse encourages the patient to set a weight loss goal of how many pounds in 4 weeks? 1 to 2 3 to 5 4 to 8 5 to 10

In developing an effective weight reduction plan for an overweight patient who expresses willingness to try to lose weight, which factor should the nurse assess first? The length of time the patient has been obese The patient's current level of physical activity The patient's social, emotional, and behavioral influences on obesity Anthropometric measurements, such as body mass index and skinfold thickness

In helping the breastfeeding mother position the baby, nurses should keep in mind that: the cradle position is usually preferred by mothers who had a cesarean birth. women with perineal pain and swelling prefer the modified cradle position. whatever the position used, the infant is "belly to belly" with the mother. while supporting the head, the mother should push gently on the occiput.

In working with teenagers, what should the nurse include when teaching about prevention of STIs? Spermicidal jellies reduce the risk of getting STIs. STIs are easily cured so prevention is not important. Abstinence and then condoms are the best prevention. Douches for women and cleaning the penis will prevent STIs.

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to: place the newborn on the abdomen (prone) after feeding and for sleep. avoid use of pacifiers. use a rear-facing car seat. use a crib with side rail slats that are no more than 3 inches apart.

Self-care instructions for a woman following a modified radical mastectomy would include that she: wears clothing with snug sleeves to support her affected arm. use depilatory creams instead of shaving the axilla of her affected arm. expect a decrease in sensation or tingling in her affected arm as her body heals. empty surgical drains once a day or every other day.

Several noted health risks are associated with menopause. These risks include all except: osteoporosis. coronary heart disease. breast cancer. obesity.

When caring for a patient with nephrotic syndrome, which food selection indicates the patient understands dietary teaching? Peanut butter and crackers One small grilled pork chop Salad made of fresh vegetables Spaghetti with canned spaghetti sauce

The nurse is conducting a therapy session for clients diagnosed with various forms of sexual dysfunction. When asked why a nurse should never engage in a sexual relationship with a client, the nurse replies most informatively when stating: "Violating sexual boundaries would be considered professional misconduct." "A nurse would surely be sued and certainly lose his or her license to practice nursing." "Such contact is never therapeutic and would ultimately harm the client emotionally." "Professional responsibilities would certainly prevent a nurse from engaging in such behavior."

The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a patient with acquired immunodeficiency syndrome (AIDS). What laboratory study result indicates the medications are effective? Increased viral load Decreased neutrophil count Increased CD4+ T cell count Decreased white blood cell count

The nurse is preparing to administer timolol eye drops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? "I have sinusitis." "I have migraine headaches a lot." "I have chronic obstructive pulmonary disease." "I have a history of chronic urinary tract infections."

The nurse is preparing to provide a client diagnosed with erectile dysfunction as a result of a spinal cord injury with an educational plan that will help address his limitations. In order to best assure a positive outcome for both the client and his sexual partner, the nurse will: educate the client and his partner on how the injury brought about the development of his limitations. assess the client's readiness to accept the limitations regarding sexual performance his injury has caused. encourage the client's partner to play an active role in contributing to the topics discussed in the educational plan. evaluate the commitment between the client and his partner and their ability to sustain such a challenge to their relationship.

The nurse is providing care for a patient who has been living with human immunodeficiency virus (HIV) for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A new onset of polycythemia Presence of mononucleosis-like symptoms A sharp decrease in the patient's CD4+ count A sudden increase in the patient's WBC count

The nurse is providing care for a patient who is a strict vegetarian. Which dietary choices would the nurse recommend to prevent iron deficiency? Brown rice and kidney beans Cauliflower and egg substitutes Soybeans and hot breakfast cereal Whole-grain bread and citrus fruits

The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? "I doubt my other eye will ever be affected." "I can expect severe pain after this procedure." "I should avoid lifting heavy objects and straining." "The procedure will correct my vision immediately."

The nurse knows that the second stage of labor, the descent phase, has begun when: the amniotic membranes rupture. the cervix cannot be felt during a vaginal examination. the woman experiences a strong urge to bear down. the presenting part is below the ischial spines.

The nurse recognizes that the majority of patients' caloric needs should come from which source? Fats Proteins Polysaccharides Monosaccharides

The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? It will gather platelets for use later when needed. It will cause anemia because it removes whole blood and red blood cells are damaged. It will remove the IgG autoantibodies and antigen complexes from the plasma. It will remove the peripheral stem cells in order to cure the autoimmune disease.

The patient with diabetes mellitus has been chronically ill with a severe lung infection needing corticosteroids and antibiotics. What condition should the nurse monitor for related to the patient's condition? Major histoincompatibility Primary immunodeficiency Secondary immunodeficiency Acute hypersensitivity reaction

Vitamin K is given to the newborn to: reduce bilirubin levels. increase the production of red blood cells. enhance ability of blood to clot. stimulate the formation of surfactant.

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? Dyspnea Precordial pain Increased pulse rate Elevated blood pressure

What is the PRIORITY teaching tip the nurse should provide about bottle-feeding? Infants may stool with each feeding in the first weeks. Feed newborn at least every 3 to 4 hours. Hold infant semiupright while feeding. Some infants take longer to feed than others.

When a client makes an attempt to hug a nurse, the nurse responds immediately by stating the behavior is sexually inappropriate and will not be tolerated. The unit's nurse manager reacts to the nurse's response by: reinforcing to the client that such behavior will not be tolerated. encouraging the nurse to ignore such innocent behaviors in the future. confirming that the nurse responded in an appropriate, therapeutic manner. explaining to the client that such behavior is often misinterpreted and should be avoided.

When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? Apply pressure to each eyeball for a few seconds after administration. Have the patient close the eyes and move them back and forth several times. Have the patient put pressure on the inner canthus of the eye after administration. Have the patient try to blink out excess medication immediately after administration.

When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: express a strong need to review events and her behavior during the process of labor and birth. exhibit a reduced attention span, limiting readiness to learn. vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. have reestablished her role as a spouse/partner.

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: massage the fundus. administer Methergine, 0.2 mg PO, that has been ordered prn. assist the woman to empty her bladder. recognize this as an expected finding during the first 24 hours following birth.

When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? Recognizing that eye damage caused by glaucoma can be reversed in the early stages Giving anticipatory guidance about the eventual loss of central vision that will occur Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is 500 to 1500 mL. 1200 to 2200 mL. 2000 to 3000 mL. 3000 to 4000 mL.

Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? Change the injection cap after the administration of IV medications. Use a 5-mL syringe to flush the catheter between medications and after use. During removal of the catheter, have the patient perform the Valsalva maneuver. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

Which description of the phases of the second stage of labor is accurate? Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies Transitional phase: woman "laboring down," fetal station is 0, duration is 15 minutes

Which hematocrit (Hct) and hemoglobin (Hgb) results represent(s) the lowest acceptable values for a woman in the third trimester of pregnancy? 38% Hct; 14 g/dL Hgb 35% Hct; 13 g/dL Hgb 33% Hct; 11 g/dL Hgb 32% Hct; 10.5 g/dL Hgb

Which instruction should the nurse provide when teaching a patient to exercise the pelvic floor? Tighten both buttocks together. Squeeze thighs together tightly. Contract muscles around rectum. Lie on back and lift the legs together.

Which measure would be least effective in preventing postpartum hemorrhage? Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered Encourage the woman to void every 2 hours Massage the fundus every hour for the first 24 hours following birth Teach the woman the importance of rest and nutrition to enhance healing

Which minerals and vitamins usually are recommended to supplement a pregnant woman's diet? Fat-soluble vitamins A and D Water-soluble vitamins C and B6 Iron and folate Calcium and zinc

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? Semirecumbent Sitting Squatting Side-lying

Which presumptive signs (felt by the woman) or probable sign (observed by the examiner) of pregnancy is not matched with another possible cause? Amenorrhea: stress, endocrine problems Quickening: gas, peristalsis Goodell sign: cervical polyps Chadwick sign: pelvic congestion

Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care? PPD symptoms are consistently severe. This syndrome affects only new mothers. PPD can easily go undetected. Only mental health professionals should teach new parents about this condition.

With regard to afterbirth pains, nurses should be aware that these pains are: caused by mild, continual contractions for the duration of the postpartum period. more common in first-time mothers. more noticeable in births in which the uterus was overdistended. alleviated somewhat when the mother breastfeeds

With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: kidney function returns to normal a few days after birth. diastasis recti abdominis is a common condition that alters the voiding reflex. fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. with adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.

he history and physical of a 29-yr-old female patient are indicative of human papillomavirus (HPV) infection. What treatment option should be discussed with the patient? Gardasil Antibiotic therapy Wart removal options Treatment with antiviral drugs

A heterosexual patient is concerned that they may contract human immunodeficiency virus (HIV) from a bisexual partner. What should the nurse include when teaching about preexposure prophylaxis (select all that apply.)? Take fluconazole (Diflucan). Take amphotericin B (Fungizone). Use condoms for risk-reducing sexual relations. Take emtricitabine and tenofovir (Truvada) regularly. Have regular HIV testing for herself and her husband.

C, D, E

A postpartum woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? (Select all that apply.) Do not perform Kegel exercises to decrease pelvic floor muscle healing time. If breastfeeding, sexual interest may be delayed. Fatigue may affect interest in sexual activity. Sexual activity can usually be safely resumed by 5 to 6 weeks after birth. Water-soluble lubrication may increase comfort. The female-on-top position may be more comfortable than other positions.

C, D, E, F

What is bluish color of vagina?

Chadwick's sign

. In order to reassure and educate pregnant clients about changes in their blood pressure, maternity nurses should be aware that: a blood pressure cuff that is too small produces a reading that is too low; a cuff that is too large produces a reading that is too high. shifting the client's position and changing from arm to arm for different measurements produces the most accurate composite blood pressure reading at each visit. the systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure remains constant. compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the latter stage of term pregnancy.

. When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? Inner canthus Outer canthus Center of the eyeball Lower conjunctival sac

. Which event discovered during pregnancy would alert the nurse that a cesarean section delivery is indicated? Contact with an individual with syphilis 2 weeks ago Treatment for gonococcal pharyngitis before conception Treatment for Chlamydia trachomatis at her 20th week of gestation Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

2. A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? "My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." "We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage."

4. Over-the-counter (OTC) pregnancy tests usually rely on which technology to test for human chorionic gonadotropin (hCG)? Radioimmunoassay Radioreceptor assay Latex agglutination test Enzyme-linked immunosorbent assay (ELISA)

A 22-year-old woman pregnant with a single fetus has a preconception body mass index (BMI) of 24. When she was seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg (4 lbs) since conception. How would the nurse interpret this? This weight gain indicates possible gestational hypertension. This weight gain indicates that the woman's infant is at risk for intrauterine growth restriction (IUGR). This weight gain cannot be evaluated until the woman has been observed for several more weeks. The woman's weight gain is appropriate for this stage of pregnancy.

A 30-yr-old woman reports the recent appearance of itchy lesions on her vulva, some of which have recently burst. Which STI should the nurse suspect first? HIV Gonorrhea Chlamydia Genital herpes

A frail 72-yr-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid? Aspirin Acetaminophen Diphenhydramine Aluminum hydroxide

A maternal serum alpha-fetoprotein (MSAFP) test is performed at 16 to 18 weeks of gestation. An elevated level has been associated with: Down syndrome. sickle cell anemia. cardiac defects. open neural tube defects such as spina bifida.

A patient being tested for multiple allergies develops localized redness and swelling in reaction to a patch skin test. Which intervention by the nurse would have the highest priority? Notify the health care provider. Administer oral diphenhydramine. Apply a topical antiinflammatory cream. Remove the patch and extract from the skin.

A patient is scheduled for a corneal transplant and is concerned regarding the difficulty with vision that may last for up to 12 months after the transplant. What is the best response by the nurse? If the transplant is done soon after the donor dies, there will not be as much trouble recovering vision. The astigmatism the patient is experiencing may be corrected with glasses or rigid contact lenses. Increasing the amount of light and using a magnifier to read will be helpful if a transplant is not wanted. There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery.

A patient received a small-bore nasogastric (NG) tube after a laryngectomy. Which action has the highest priority before initiating enteral feedings? Testing aspirated fluid pH Auscultating while instilling air Elevating head of bed to 40 degrees Verifying NG tube placement on x-ray

A patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? Cough, diarrhea, headaches, blurred vision, muscle fatigue Night sweats, fatigue, fever, and persistent generalized lymphadenopathy Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea

A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Irrigate the tube between feedings. Provide wound care at the gastrostomy site. Administer prescribed liquid medications through the tube. Position the patient with a 45-degree head of bed elevation.

A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? Teach about visual enhancement techniques. Teach nutritional strategies to improve vision. Assess coping strategies and support systems. Assess impact of vision on normal functioning.

A patient with septic shock is receiving multiple medications. Which intravenous (IV) medication is most likely to cause a hearing loss? Dopamine Ampicillin Aspirin Vancomycin

A pregnant woman at 32 weeks of gestation complains of feeling dizzy and light-headed while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to: assess the woman's blood pressure and pulse. have the woman breathe into a paper bag. raise the woman's legs. turn the woman on her side.

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: weight gain of 1 to 3lbs. quickening. fatigue and lethargy. bloody show

A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner before she became pregnant. She has abstained during her first trimester and would like to know if it is safe for her to have a drink with dinner now. The nurse tells her: "Because you're in your second trimester, there's no problem with having one drink with dinner." "One drink every night is too much. One drink three times a week should be fine." "Because you're in your second trimester, you can drink as much as you like." "Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy."

After identifying that a patient has possible nutritional deficits, which action will the nurse perform next? Provide supplements between meals. Encourage eating meals with others. Have family bring in food from home. Complete a full nutritional assessment.

An expectant couple asks the nurse about intercourse during pregnancy and if it is safe for the baby. The nurse should tell the couple that: intercourse should be avoided if any spotting from the vagina occurs afterward. intercourse is safe until the third trimester. safer-sex practices should be used once the membranes rupture. intercourse and orgasm are often contraindicated if a history or signs of preterm labor are present.

At the first visit to the clinic, the female patient with a BMI of 29 kg/m2 tells the nurse that she does not want to become obese. Which question used for assessing weight issues would be most effective? "What factors contributed to your current body weight?" "How is your overall health affected by your body weight?" "What is your history of gaining weight and losing weight?" "In what ways are you interested in managing your weight differently?"

During the course of an interview to assess vision, a patient complains of dry eyes. What should the nurse implement next? Assess for contact lenses. Suggest saline eye drops. Ask about eyeglass usage. Check the medication list.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: tell the woman she can rest after she feeds her baby. recognize this as a behavior of the taking-hold stage. record the behavior as ineffective maternal-newborn attachment. take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.

If exhibited by a pregnant woman, what represents a positive sign of pregnancy? Morning sickness Quickening Positive pregnancy test Fetal heartbeat auscultated with Doppler/fetoscope

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: the woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. having the woman point her toes reduces leg cramps. the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.

In the immediate postoperative period a nurse cares for a severely obese 72-yr-old man who had surgery for repair of a lower leg fracture. Which assessment is most important? Cardiac rhythm Surgical dressing Postoperative pain Oxygen saturation

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: begin an IV infusion of Ringer's lactate solution. assess the woman's vital signs. call the woman's primary health care provider. massage the woman's fundus.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: uses soap and warm water to wash the vulva and perineum. washes from the symphysis pubis back to the episiotomy. changes her perineal pad every 2 to 3 hours. uses the peribottle to rinse upward into her vagina.

Postbirth uterine/vaginal discharge, called lochia: is similar to a light menstrual period for the first 6 to 12 hours. is usually greater after cesarean births. will usually decrease with ambulation and breastfeeding. should smell like normal menstrual flow unless an infection is present.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash on the palms and soles, jaundice, and diarrhea. What does the nurse determine these clinical manifestations are indicating? The patient is experiencing a type I allergic reaction. An atopic reaction is causing the patient's symptoms. The patient is experiencing rejection of the bone marrow. Cells in the transplanted bone marrow are attacking the host tissue.

The nurse advises the woman who wants to have a nurse-midwife provide obstetric care that: she will have to give birth at home. she must see an obstetrician as well as the midwife during pregnancy. she will not be able to have epidural analgesia for labor pain. she must be having a low-risk pregnancy.

The nurse identifies which priority nursing invention for a patient with hyperthermia? Initiating seizure precautions Limiting oral intake Providing a blanket Removing excess clothing

The nurse instructs a patient prescribed dipivefrin eye drops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? "The eye drops could cause a fast heart rate and high blood pressure." "I will need to take the eye drops twice a day for at least 2 to 3 months." "I may experience eye discomfort and redness from the use of these eye drops." "I will apply gentle pressure on the inside corner of my eye after each eye drop."

The nurse is assessing an older adult patient who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess for the presence of presbycusis? "Do you ever experience any ringing in your ears?" "Have you ever fallen down because you became dizzy?" "Do you ever have pain in your ears when you're chewing or swallowing?" "Have you noticed any change in your hearing in recent months and years?"

The nurse is caring for a 73-yr-old male patient with a history of benign prostatic hyperplasia and symptoms of a urinary tract infection. Which diagnostic finding would support this diagnosis? White blood cell count is 7500 cells/µL. Antistreptolysin-O (ASO) titer is 106 Todd units/mL. Glucose, protein, and ketones are present in the urine. Nitrites and leukocyte esterase are present in the urine.

The nurse is providing care for a patient admitted to the hospital for treatment of nephrotic syndrome. What are the priority nursing assessments? Assessment of pain and level of consciousness Assessment of serum calcium and phosphorus levels Blood pressure and assessment for orthostatic hypotension Daily weights and measurement of the patient's abdominal girth

The nurse is providing postoperative care for a patient with human immunodeficiency virus (HIV) infection after an appendectomy. What type of precautions should the nurse observe to prevent the transmission of this disease? Droplet precautions Contact precautions Airborne precautions Standard precautions

The nurse is reviewing the laboratory test results for a patient with metastatic lung cancer who was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. How will the nurse interpret these results? The albumin level is normal therefore the patient does not have protein malnutrition. The albumin level is increased, which is common in patients with cancer who have malnutrition. Both the serum albumin and prealbumin levels are reduced, consistent with the diagnosis of malnutrition. Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

The nurse is teaching a patient about timolol eye drops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? "I may feel some palpitations after instilling these eye drops." "I should withhold this medication if my blood pressure becomes elevated." "I should keep my eyes closed for 15 minutes after instilling these eye drops." "I may have some temporary blurring of vision after instilling these eye drops."

The nurse is teaching a patient with a latex allergy about preventing and treating allergic reactions. Which statement, if made by the patient, indicates a need for further teaching? "My dentist should be told about my latex allergy." "I should avoid foods such as bananas, avocados, and kiwi." "I will use vinyl gloves for activities such as housekeeping." "Because my reactions are not severe, I will not need an EpiPen."

The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? "Prolonged eye irritation is an expected adverse effect of this medication." "This medication will help to raise intraocular pressure to a near normal level." "This medication needs to be continued for at least 5 years after your initial diagnosis." "It is important not to do activities requiring visual acuity immediately after administration."

The nurse obtains a history from a 34-yr-old woman diagnosed with a chlamydial infection. Which patient statement indicates additional teaching is required? "This infection can be cured by taking antibiotics." "It is important to use condoms for all sexual activity." "I will avoid sexual contact for 1 week after taking the antibiotics." "My sexual partner does not have symptoms and will not need treatment."

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A patient with a traumatic brain injury A patient with type 1 diabetes mellitus A patient with acute respiratory failure A patient with nasogastric tube suction

The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? Administer IV diphenhydramine. Administer nitroprusside as soon as possible. Anticipate tracheostomy with laryngeal edema. Place the patient recumbent and elevate the legs.

The severely obese patient has elected to have the Roux-en-Y gastric bypass (RYGB) procedure. The nurse will know the patient understands the preoperative teaching when the patient makes which statement? "This surgery will preserve the function of my stomach." "This surgery will remove the fat cells from my abdomen." "This surgery can be modified whenever I need it to be changed." "This surgery decreases how much I can eat and how many calories I can absorb."

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects: bladder distention uterine atony constipation hematoma formation

What laboratory results would be a cause for concern if exhibited by a woman at her first prenatal visit during the second month of her pregnancy? Hematocrit 38%, hemoglobin 13 g/dL White blood cell count 6000/mm3 Platelets 300,000/mm3 Rubella titer 1:6

When a nurse shares that discussing sex-related topics in group sessions is uncomfortable for the clients and should be avoided, the nurse's nursing mentor replies: "Such conversations are appropriate only when the client initiates the discussion." "I agree; such conversations should be conducted by specially trained professionals." "If the client is uncomfortable with the topic, they know they can always leave the group." "Clients are often reluctant to ask sex-related questions until the nurse opens up the topic."

When counseling a client about getting enough iron in her diet, the maternity nurse should tell her that: milk, coffee, and tea aid iron absorption if consumed at the same time as iron. iron absorption is inhibited by a diet rich in vitamin C. iron supplements are permissible for children in small doses. constipation is common with iron supplements.

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: place the thermistor probe on the left side of the chest. cover the probe with a nonreflective material. recheck the temperature by periodically taking a rectal temperature. prewarm the radiant heat warmer and place the undressed newborn under it.

A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? Nausea and vomiting Hyperactive bowel sounds Firmly distended abdomen Abrasions on all extremities

What is softening of the uterus?

Hagar's sign

What are the 5 cardinal signs of inflammation?

Heat, redness, swelling, pain, loss of function

What is the time from the onset of true labor until the birth of the infant and the placenta?

Intrapartum

A pregnant woman's last menstrual period began on April 8, 2009, and ended on April 13. Using Nägele's rule, her estimated date of birth would be________.

January 15, 2010

The nurse is preparing to administer famotidine to a postoperative patient with a colostomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate? "It will reduce the amount of acid in the stomach." "It will prevent air from accumulating in the stomach, causing gas pains." "It will prevent the heartburn that occurs as a side effect of general anesthesia." "The stress of surgery is likely to cause stomach bleeding if you do not receive it."

What is it called at initial HIV infection when there are large viral levels in the blood?

Viremia

A 47-yr-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6ºF (30.3ºC). Which nursing action is most important? Administer warmed IV fluids. Position patient under a radiant heat lamp. Place an air-filled warming blanket on the patient. Immerse the extremities in a water bath (102° to 108°F [38.9° to 42.2°C]).

A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse? Fecal impaction Perineal hygiene Dietary fiber intake Antidiarrheal agent use

An 18-yr-old man who fell through the ice on a pond near his farm was admitted to the emergency department with somnolence. Vital signs are blood pressure of 82 mm Hg systolic with Doppler, respirations of 9 breaths/min, and core temperature of 90°F (32.2°C). The nurse should anticipate which intervention? Active core rewarming Immersion in a hot bath Rehydration and massage Passive external rewarming

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Maintain a high intake of fluid and fiber in the diet. Discontinue intake of medications causing constipation. Eat several small meals per day to maintain bowel motility. Sit upright during meals to increase bowel motility by gravity

The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? "The tube will help to drain the stomach contents and prevent further vomiting." "The tube will push past the area that is blocked and thus help to stop the vomiting." "The tube is just a standard procedure before many types of surgery to the abdomen." "The tube will let us measure your stomach contents so we can give you the right IV fluid replacement."

The nurse should document which physiological stressor after performing a screening assessment on a patient? Dementia Caregiving of parent Divorce Death of friend

The wound, ostomy, and continence nurse (WOCN) selects the site where the ostomy will be placed. What should be included in site consideration? The patient must be able to see the site. The site should be outside the rectus muscle area. It is easier to seal the drainage bag to a protruding area. A waistline site will allow using a belt to hold the appliance in place.

Three days after experiencing a series of tick bites, a patient presents to the emergency department. Which manifestation would indicate the patient is experiencing tick paralysis? Respiratory distress Aggression and frequent falls Decreased level of consciousness Fever and necrosis at the bite sites

Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event? Impaired peristalsis Irritation of the bowel Nasogastric suctioning Inflammation of the incision site

When evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching? "I will be able to regulate when I have stools." "I will be able to wear the pouch until it leaks." "The drainage from my stoma can damage my skin." "Dried fruit and popcorn must be chewed very well."

Which assessment parameter will the nurse address during the secondary survey of a patient in triage? Blood pressure and heart rate Patency of the patient's airway Neurologic status and level of consciousness Presence or absence of breath sound and quality of breathing

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow? Patients should be routinely screened for family and IPV. Patients whom the nurse deems high risk should be assessed for IPV. All female patients and patients under 18 should be assessed for IPV. Patients should be assessed for IPV provided corroborating evidence exists.

A nurse in the emergency department is working triage. Which patient assessment findings would indicate immediate care is required? Shortened and externally rotated leg Inability to swallow and move the left arm Warm, edematous, reddened and painful calf Yellow sputum and pain with deep inspiration

A nurse is performing triage in the emergency department. Which patient should the nurse see first? A 18-yr-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg A 32-yr-old patient with drug overdose who is unresponsive with a poor respiratory effort A 56-yr-old patient with substernal chest pain who is diaphoretic with shortness of breath A 78-yr-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg

A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse? 2 to 5 minutes 15 to 60 minutes 2 to 4 hours 6 to 8 hours

A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? 7:00 AM, 10:00 AM, and 1:00 PM 8:00 AM, 12:00 PM, and 4:00 PM 9:00 AM and 3:00 PM 9:00 AM, 12:00 PM, and 3:00 PM

The nurse identifies that which patient is at highest risk for developing colon cancer? A 28-yr-old man who has a body mass index of 27 kg/m2 A 32-yr-old woman with a 12-year history of ulcerative colitis A 52-yr-old man who has followed a vegetarian diet for 24 years A 58-yr-old woman taking prescribed estrogen replacement therapy

The nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer? Osteoarthritis History of colorectal polyps History of lactose intolerance Use of herbs as dietary supplements

The nurse should administer an as-needed dose of magnesium hydroxide after noting what information when reviewing a patient's medical record? Abdominal pain and bloating No bowel movement for 3 days A decrease in appetite by 50% over 24 hours Muscle tremors and other signs of hypomagnesemia

What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy? How to care for the wound How to deep breathe and cough The location and care of drains after surgery Which medications will be used during surgery

when is antepartum?

before childbirth

26. A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member? A nursing assistant on the unit who also has hospice experience A licensed practical nurse that has worked on the unit for 10 years A registered nurse with 6 months of experience on the surgical unit A registered nurse who has floated to the surgical unit from pediatrics

A distinguishing factor of psychosis is that it: is caused by moderate to severe anxiety. incorporates delusions into an individual's reality. results in a significant misrepresentation of what is real. is dependent on an individual's baseline cognitive function.

A male patient is brought into the emergency department with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority? Guard locked access doors. Maintain patient safety from revenge. Maintain personal and work place safety. Attain open patient airway and breathing.

A nurse teaches the emergency department staff about their roles during a mass casualty incident. Which primary responsibility is expected of all licensed and unlicensed health care staff? Notify local, state, and national authorities. Assist security personnel to patrol the area. Learn the hospital emergency response plan. Contact the American Red Cross for assistance.

The nurse working at a women's health clinic is seeing a teenage female patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain. When the nurse enters the room, the patient is sitting in the chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be important for the nurse to ask the patient? a. "What brings you to the clinic today?" b. "What can we do to help you today?" c. "Do you feel safe in your current relationship?" d. "Have you changed your diet lately?"

Which statement demonstrates an expression of anxiety rather than fear? "I can't stand spiders." "You'd never get me on a roller coaster." "I really dislike knowing that we have a 50-point test tomorrow." "I can't imagine why anyone would want to parachute out of an airplane."

Which clinical manifestations of inflammatory bowel disease does the nurse determine are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply.)? Restricted to rectum Strictures are common Bloody, diarrhea stools Cramping abdominal pain Lesions penetrate intestine

c, d

. The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question? Bisacodyl Lubiprostone Cascara sagrada Magnesium hydroxide

9. A mass casualty incident was identified on a nearby freeway. Which patient would likely be designated "red" during triage at the site? An individual who is distraught at the violence of the incident An individual who has experienced an open arm fracture from falling debris An individual who is not expected to survive a crushing head and neck wound An individual whose femoral artery has been severed and is bleeding profusely

The nurse requests a patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? Ask family members whether they have discussed the surgical procedure with the physician. Have the patient sign the form and state the physician will visit to explain the procedure before surgery. Explain the planned surgical procedure as well as possible and have the patient sign the consent form. Delay the patient's signature on the consent and notify the physician about the conversation with the patient.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? White bread, cheese, and green beans Fresh tomatoes, pears, and corn flakes Oranges, baked potatoes, and raw carrots Dried beans, All Bran (100%) cereal, and raspberries

he nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? Write an incident report about this untoward event. Attempt to have the family convince the patient to take the ordered dose. Withhold the medication at this time and try to administer it later in the day. Chart the dose as not given on the medical record and explain in the nursing progress notes.

What is the biggest SLE flare sign?

fever

When does rubra occur?

first 3-4 days

When do you assess for "baby blues"?

first 7-10 days

What is softening of the cervix?

goodell's sign

What is most common cause of death related to kidney things?

infection

What is the #1 cause of SLE death?

kidney damage

When do severe immune problems start with CD4 levels?

less than 200

What is obesity BMI?

more than 30

What vaccines do you give after birth?

rubella, varicella, and pertussis

What does aldosterone do?

water retention

. A 24-yr-old woman donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is experiencing significant pain and refuses to get up to walk. How should the nurse respond? Have the transplant psychologist convince her to walk. Encourage even a short walk to avoid complications of surgery. Tell the patient that no other patients have ever refused to walk. Tell the patient she is lucky she did not have an open nephrectomy.

"You are the nurse assessing the mental status of a patient in acute kidney failure. If there is an abnormal finding, which condition is most likely the cause?" a) Anger r/t denial of a chronic disease b) Delirium r/t hypoxia of brain cells c) confusion r/t increased urea levels d) Aggression r/t possible underlying comorbidities

The nurse is trying a nonpharmacological intervention for a patient with anxiety. Which of the following would most likely benefit this patient? Increasing caffeine intake Decreasing physical activity Limiting noise or music in the room Performing abdominal breathing exercises

The nurse preparing to administer a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? Sodium Potassium Magnesium Phosphorus

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for a lab draw to check the serum sodium concentration? a) Development of ankle or sacral edema b) Increased skin tenting and dry mouth c) Postural hypotension and tachycardia d) Decreased level of consciousness

he nurse is completing a care plan for a patient who is exhibiting poor coping after receiving a serious medical diagnosis. Which interventions would the nurse consider? (Select all that apply.) Recommend a glass of wine before dinner each night for relaxation. Compile a list of activities that are of interest to the patient. Review pamphlets about treatment options with the patient. Identify positive aspects of the illness, such as the chance to spend more time with family. Reinforce the fact that the medical team can make treatment decisions, so the patient does not need to worry.

B, C, d

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) Assess for bradycardia. Ask about epigastric pain. Observe for increased appetite. Check for elevated blood glucose levels. Monitor for a decrease in respiratory rate.

B, c, d

A 52-yr-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform? Assess skin turgor to determine hydration status. Insert a urinary catheter for the expected diuresis. Evaluate the patient's lower extremities for edema. Check the patient's urine for the presence of ketones.

The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? Monitor the patient's cardiac status. Teach the patient about hand washing. Obtain a serum specimen for electrolytes. Increase direct observation of the patient.

When describing the results of the fight or flight response, the nursing students require further teaching when making which statement? Pupils constrict when a patient is anxious. The heart races when a patient experiences anxiety. Peristalsis slows as the patient decides whether to fight back. The patient may complain of dry mouth when anxious

You are the ER trauma nurse when a 120 pound burn patient comes into the ER. The patient was caught in a kitchen oil fire and has sustained burns to her face, the top third of her torso and her hands. It is your responsibility to figure her resuscitation fluid rate using the Parkland formula and rule of nines. At what rates should the first and second half of her fluid resuscitation run? a) first half - 230 ml/hr & second half - 115 ml/hr b) first half - 115 ml/hr & second half - 230 ml/hr c) first half 150 ml/ hr & second half - 75 ml/hr d) first half - 75 ml/hr & second half - 150 ml/hr

A diabetic patient who is hospitalized asks the nurse what factors are associated with increased blood glucose while in the hospital. Which response(s) by the nurse are appropriate? (Select all that apply.) Blood sugar may be higher in the hospital due to the increased bed rest. Stressors such as illness cause the release of hormones that increase blood sugar. Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times. A patient's diet is different here in the hospital than at home, and that is the most likely because of the increased glucose level. Medications such as steroids may increase glucose levels.

A, b, e

Which of the following statements is true regarding anxiety? (Select all that apply.) Anxiety is a response to stress. Anxiety is uncommon in women. Anxiety can cause elevations in blood pressure and heart rate. Many conditions are exacerbated by stress and anxiety. Patients with anxiety respond well to relaxation techniques. Children are at the highest risk for anxiety.

A, c, d, e

A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.

A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns? Serum sodium Serum potassium Serum total calcium Serum magnesium

A patient with end-stage renal disease (ESRD) secondary to diabetes mellitus has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? Level of consciousness Blood pressure and fluid balance Temperature, heart rate, and blood pressure Assessment for signs and symptoms of infection

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. Which strategy is used to achieve ultrafiltration in peritoneal dialysis? Increasing the pressure gradient Increasing osmolality of the dialysate Decreasing the glucose in the dialysate Decreasing the concentration of the dialysate

The home care nurse visits a 34-yr-old woman receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse? "Drain time is faster if I rub my abdomen." "The fluid draining from the catheter is cloudy." "The drainage is bloody when I have my period." "I wash around the catheter with soap and water."

The nurse is assessing the coping abilities of a patient recently diagnosed with a degenerative neuromuscular disease with no known cure. Which statement by the patient alerts the nurse that more intervention is needed? "I have decided to take some art lessons at the community center." "I am sleeping much better when I have two drinks and smoke before bed." "I am scheduling a family reunion for the upcoming holiday." "I have decided to sell my house and move into an apartment with my son."

The nurse is caring for a 68-yr-old man who had coronary artery bypass surgery 3 weeks ago. During the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? Provide foods high in potassium. Restrict fluids based on urine output. Monitor output from peritoneal dialysis. Offer high-protein snacks between meals.

Which assessment question is particularly important to ask of a veteran of the Iraq conflict? a. "Have you ever experienced a migraine headache?" b. "Could you ever see yourself considering suicide?" c. "Do you feel anxious when you find yourself in a confined space like an elevator?" d. "Would you say that your sleep patterns provide you with sufficient amounts of recuperative rest?"

Which child has the highest risk for developing a psychiatric problem as an adult? The 10-year-old whose leg is amputated as a result of bone cancer The 5-year-old who anxiously calls for his mother who died in a car accident The 3-year-old whose father has been diagnosed with obsessive-compulsive disorder (OCD) The 8-year-old whose foster grandfather was diagnosed with paranoid schizophrenia at age 15

Which patient has the most significant risk factors for CKD? A 50-yr-old white woman with hypertension A 61-yr-old Native American man with diabetes A 40-yr-old Hispanic woman with cardiovascular disease A 28-yr-old African American woman with a urinary tract infection

Which statement made by an 11-year-old who recently experienced the loss of his father best demonstrates the characteristic of resilience? "Mommy and I will see daddy every night in our dreams." "I'll really miss my daddy but I know mom and I will be okay." "Now that daddy is gone, I'll take care of mommy like he did." "Daddy wouldn't want me to cry so I'll be a big boy for him."

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? Fully compensated respiratory alkalosis Partially compensated respiratory acidosis Normal acid-base balance with hypoxemia Normal acid-base balance with hypercapnia

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider? Antibiotics Loop diuretics Bronchodilators Antihypertensives

The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? Extracellular fluid volume (ECV) excess Extracellular fluid volume (ECV) deficit Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia

B, C, E

A 10-year-old child has been diagnosed with acute depression after the death of a beloved grandparent. His parents ask how it is that someone so young can become depressed. The nurse responds: "He was obviously very attached to his grandfather; his grief will pass as will the depression." "Depression is triggered by many different events; the loss of a loved one is a primary one for your son." "We can have a predisposition to being depressed; when the right trigger happens the depression occurs." "Everyone gets depressed; age and gender really have little importance on whether we experience depression or not."

A 56-yr-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. Which finding will the nurse monitor for? Fatigue Hypoglycemia Cardiac dysrhythmias Elevated triglycerides

A member of the military shares that he has been a victim of sexual trauma during his enlistment. Which question will the nurse ask to best assess the individual's degree of self-blame? a. "Were you physically hurt as a result of sexual abuse?" b. "Have you confided this information with family or a trusted friend?" c. "What occurred when you reported the attack to your military superior?" d. "Have you been tested for sexually transmitted diseases since the attack?"

A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery? Hypokalemia Hyponatremia Large urine output Leukocytosis with cloudy urine output

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? Administer hypertonic saline. Administer a blood transfusion. Decrease the rate of fluid removal. Administer antiemetic medications.

The nurse is about to assess the possible incidence of sexual abuse. Based on an understanding of how males and females experience and internalize sexual trauma differently, the nurse would ask the male soldier: a. "Have you ever been sexually abused?" b. "Have you ever felt victimized sexually by anyone?" c. "Has an unwanted sexual advance by anyone ever made you feel harassed or confused?" d. "Has a superior officer ever made an unwanted sexual advancement that you felt you had to agree to?"

The nurse is assessing a patient's coping abilities related to expected placement in a long-term care facility. Which risk factor is of most concern to the nurse? The patient's family members all live several hours away. The patient is a retired police officer. The patient was recently diagnosed with Alzheimer's disease. The patient will need assistance in moving from his home.

The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? Hemodialysis (HD) three times per week Automated peritoneal dialysis (APD) Continuous venovenous hemofiltration (CVVH) Continuous ambulatory peritoneal dialysis (CAPD)

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? Polyuria Bradycardia Restlessness Difficulty breathing

Which nursing intervention is most appropriate when caring for a patient with dehydration? Monitor skin turgor every shift. Auscultate lung sounds every 2 hours. Monitor daily weight and intake and output. Encourage the patient to reduce sodium intake.

Which of the following actions demonstrates a potential problem with an adolescent's establishment of ego competency skills? Saving all his birthday money and most of his allowance so he can go to camp next summer Spending the weekend with grandparents working on a school science project Deciding to quit music lessons after a few weeks so he can join the track team Writing each night in a personal diary

Which statement made by a female military personnel currently deployed in a war zone provides the best evidence that the soldier is not feeling any unhealthy guilt over being separated from family? a. "My family back home realizes I miss and love them but leaving them was a part of my job." b. "When I get back, I will make up for the time I've been away from my family, especially my children." c. "The guilt I feel for leaving my family is offset by the pride they have for me serving my country like this." d. "Being away from my children and spouse is too hard to do again; when my enlistment is finished, I'm leaving the military."

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon. Notify the health care provider and complete an incident report. Listen to the patient's lung sounds and assess respiratory status. Asses the patient's cardiovascular status by checking pulse and blood pressure.

You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? Sodium, 136 mEq/L; potassium, 3.6 mEq/L Sodium, 145 mEq/L; potassium, 4.8 mEq/L Sodium, 135 mEq/L; potassium, 4.5 mEq/L Sodium, 144 mEq/L; potassium, 3.7 mEq/L

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? a) Raise bed side rails due to potential decreased level of consciousness and confusion. b) Examine sacral area and patient's heels for skin breakdown due to potential edema c) Establish seizure precautions due to potential muscle twitching, cramps, and seizures d) Institute fall precautions due to potential postural hypotension and weak leg muscles

When caring for a patient during the oliguric phase of acute kidney injury (AKI), which nursing action is appropriate? Weigh patient three times weekly. Increase dietary sodium and potassium. Provide a low-protein, high-carbohydrate diet. Restrict fluids according to previous daily loss

A nurse has begun working in a new unit with high-acuity patients who are scheduled for numerous diagnostic tests before being transferred to the appropriate medical or surgical unit. She also has care responsibilities for her children and her aging parents. The nurse is experiencing signs of being overwhelmed. What counsel might the nurse manager share with the nurse to help her cope with work stress? Take some time off to decide if she really wants to be a nurse. Encourage her to catch up on her documentation responsibilities while taking her lunch break. Enlist the help of other family members in the care of her children so she can focus on work. Request that another nurse help her focus on essential aspects of care rather than optional aspects of care.

A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? "I should drink a lot of tap water today." "I need to take more calcium tablets today." "I should avoid fruits with potassium in them." "I need to drink liquids with some sodium in them."

A patient has come to the health clinic for an annual checkup. He reports an increase of stress at work and having to work a lot of mandatory overtime hours. He has not been able to do his usual daily exercise for several weeks. What is the best response by the nurse? "There are other ways you can reduce your stress, such as cutting back on your work hours." "Have you considered a medication to help you sleep at night?" "Including exercise in your schedule will just increase the stress from work." "Regular exercise would be good because it helps the body deal with stress."

A patient with a 25-year history of type 1 diabetes mellitus is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood sugars. Which diagnostic study is most indicative of chronic kidney disease (CKD)? Serum creatinine Serum potassium Microalbuminuria Calculated glomerular filtration rate (GFR)

Parents are concerned that their third-grade child has been displaying behaviors similar to those of attention-deficit/hyperactivity disorder (ADHD). Which assessment question demonstrates an understanding of the similarities between behaviors of other likely diagnoses? "Were you able to quit smoking during your pregnancy?" "Do you think that your child gets enough rest at night?" "How much alcohol did you drink during your pregnancy?" "Does your child seem particularly irritable?"

Six months after returning from a combat zone, a discharged Marine reports having both memory and concentration problems that resulted in earning failing grades in two college courses. An understanding of the pathophysiology of traumatic brain injury would prompt the nurse to initially ask: a. "Were you ever treated for a traumatic brain injury?" b. "Were you ever hit on the head during your military deployment?" c. "Has a blow to the head ever resulted in you being unconscious for more than 20 minutes?" d. "When did the memory problems and difficulty with concentration begin to affect your schoolwork

The nurse is reviewing case files for children at risk for injury resulting in brain injury. Which child is at most risk for experiencing this type of violence? a. A Caucasian, six-month-old infant living with a single mother b. An African-American, 24-month-old child living with her grandmother c. A Mexican, three-year-old child living in an inner city apartment d. A Japanese, eight-year-old child living in a home with three generations of family

The nurse is talking with a group of parents with children in the military. When a father asks what effect combat will have on his daughter the nurse replies: "It is difficult to say because your daughter is experiencing things whose effects on women haven't been studied yet." "Your daughter's military training will help prepare her for the emotional stressors that combat inevitably creates." "Having loving, involved parents like you will have a huge impact on her ability to cope effectively with the stressors she's experiencing." "Women have historically been better prepared to manage the stress of aggression since they have been victims of abuse for centuries."

Which action is a demonstration of an affective response to anxiety? Lacking the patience to help an 8-year-old with homework Startling dramatically each time the telephone rings Experiencing frightening nightmares about dying Having little interest in eating or drinking

The nurse is admitting a child with a history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment? (Select all that apply.) a. Reliving abuse incidents b. Sleep disturbance c. Overeating d. Acting out behaviors e. Intermittent fever

a b, c, d

A military veteran is diagnosed with tinnitus. The educational material provided by the nurse related to the condition should include: (Select all that apply.) a. exposure to repeated loud noises is often the cause of the disorder. b. the primary characteristic is a persistent ringing in the ears. c. tinnitus may be either temporary or chronic. d. the symptoms can be expected to worsen over time. e. surgery on the eardrum is usually recommended.

a, b, c

Female military personnel who have recently returned from deployment in a war zone are being assessed for potential physical and sexual assault as well as for an increased risk for developing posttraumatic stress disorder (PTSD). During the assessment, the nurse would ask: (Select all that apply.) a. "How safe did you feel while you were deployed?" b. "Did you have much contact with potential enemy soldiers?" c. "Have you ever experienced physical abuse as either a child or an adult? d. "Do you feel the military is prepared to help you reenter a noncombat environment?" e. "What is your greatest fear regarding your personal safety as a member of the military community?"

a, b, c

A military veteran is diagnosed with heart disease. With this medical history and a military background that included two tours of duty in a combat zone abroad, the nurse assesses for related psychiatric disorders by asking: (Select all that apply.) a. "When was the last time you accidentally hurt yourself?" b. "Have you ever experienced a migraine headache?" c. "Do you have problems falling asleep at inappropriate times?" d. "Can you describe your usual pattern of bowel elimination?" e. "Would you describe yourself as forgetful or absentminded?"

a, b, c, e

Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI) (select all that apply.)? Dehydration Hypokalemia Hypernatremia BUN increases Urine output increases Serum creatinine increases

a, b, e

The nurse is assessing a patient's anxiety related to stress. Which changes reflect the short-term physiological response to stress? (Select all that apply.) Cortisol is released, increasing glycogenesis and reducing fluid loss. Immune system functioning decreases, and the risk of cancer increases. Corticosteroid release increases stamina and impedes digestion. Muscular tension, blood pressure, and triglyceride levels increase. Epinephrine is released, increasing the heart and respiratory rates. Risk of depression, autoimmune disorders, and heart disease increases.

a, c, d, e

Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD) (select all that apply.)? Anemia Dehydration Hypertension Hypercalcemia Increased risk for fractures Elevated white blood cells

a, c, e

Which nursing interventions are likely to help the patient to cope by addressing the mediators of stress? (Select all that apply.) "A divorce, while stressful, can be the beginning of a new, better phase of life." "You said you used to jog; getting back to aerobic exercise could be helpful." "Journaling gives one more awareness of how experiences have affected them." "Perhaps a short-term loan from your father will make your layoff less stressful." "Slowing your breathing by counting to three between breaths will calm you." "I have found a support group for newly divorced persons in your neighborhood."

a, d, c, f

A newly admitted client diagnosed with obsessive-compulsive disorder is exhibiting severe anxiety. Which intervention demonstrates that the nurse understands the principles related to the therapeutic management of this client? The client is encouraged to talk about his rituals and how they help him manage his anxiety. The nurse ignores the client's rituals so as to not interfere with his established coping mechanisms. The client is asked to limit the number of times he performs his ritual to encourage control over his anxiety. The nurse asks the client to explain why the rituals appear to relieve his anxiety in an attempt to have him reflect on his behavior.

An army veteran tells the nurse that he was unconscious for about 30 minutes after being involved in a bombing incident while in the Middle East. The nurse follows up on outcomes of the event by asking: "Can you remember anything about the bombing?" "Do you think the bombing affected you in any way?" "Were you inside of a vehicle when the bombing occurred?" "Did anyone confirm that you had experienced a head injury?"

Critical Thinking: A crisis intervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population? a. There is not a good legal pathway to help persons in abusive relationships. b. The abused person may return to the abusive home setting. c. Hospital policies do not identify the legal care needed for abused persons. d. Because length of care is short in the emergency department, there is little staff can do for patients who have been abused.

Several nurses are newly assigned to a hospital unit that focuses on the care of military personnel who have sustained severe brain injuries and their families. The nurse manager would initially suggest that they: a. focus on honing their therapeutic communication and assessment skills. b. self-reflect concerning their feelings about working with the disabled. c. learn to recognize and act upon the emotional needs of the family. d. review the physical needs of the traumatic brain injured client.

The nurse is seeing a patient who has been in the clinic eight times in the past 6 months for injuries from an abusive partner. The patient states, "I don't see any way to get away from my partner, and I can't keep going on like this." What assessment question is most important for the nurse to ask? a. "Do you have any family in the area that can help?" b. "Have you thought about hurting yourself or someone else?" c. "Have you thought about moving to a different city?" d. "Have you discussed this with anyone else?

The nurse regularly screens military veterans for depression and suicidal ideation based on research that supports that this population has: a working knowledge of and access to firearms. a substantially increased risk for self-harm. incidences of catastrophic emotional responses for years after discharge. the tendency to rely upon coping mechanisms that are generally aggressive.

Which information noted on a psychosocial assessment is of greatest concern when identifying risk factors for the possible development of posttraumatic stress disorder (PTSD) for a soldier about to be deployed to a war zone? a. A parent has been diagnosed with severe and persistent anxiety b. The soldier had an extended tour of duty in a war zone previously c. As a child the soldier survived a major hurricane that killed a sibling d. The spouse has suggested that their relationship may not survive this separation

Which interventions address the most commonly identified sources of risk to the mental health of military personnel and their dependents? (Select all that apply.) a. Depression support groups for adolescent dependents of military personnel b. Outpatient mental health services conveniently located near on-base housing c. Low-interest loans to assist dependent families in the payment of relocation expenses d. Relocation orders being delayed for families with school-age children so the move can occur during the summer months e. Access to on-base Internet communication resources to facilitate communication between deployed personnel and their families

b, c, e

A military veteran is being evaluated for traumatic brain injury (TBI). Which nursing assessment data supports such a diagnosis? (Select all that apply.) a. Baseline blood pressure is 148/96 b. Has been treated for bronchitis twice in the last 8 months c. Patient reports experiencing an average of 3 headaches per week d. Petit mall seizure activity well controlled with antiseizure medication therapy e. Patient reports a weight gain of 15 pounds since returning from deployment 12 months ago.

c, d

A 35-year-old army combat veteran is being treated for migraines and hypertension. The nurse is particularly interested in the individual's response to which mental health-focused question? "Are you worried about anything in particular? "Is there any history of suicide in your family?" "Have you ever experienced a hallucination?" "How would you describe posttraumatic stress disorder?

A combat experienced military veteran with a diagnosis of depression is concerned about adjusting to civilian life and reconnecting with family and friends. In assisting the individual's long-term readjustment, the mental health nurse would suggest a referral to: a. job retraining programs. b. family and marital counseling sessions. c. civilian employment assistance services. d. support groups comprised of combat veterans.

A patient has begun smoking again and drinks six alcoholic beverages per day since experiencing the loss of his job. The nurse recognizes that the patient is exhibiting symptoms of which type of stress? Psychological Emotional Physiological Behavioral

The difference between moderate and severe anxiety is that: severe anxiety centers on panic behavior. moderate anxiety motivates learning and creativity. the person experiencing severe anxiety is unable to focus on details of any kind. a person experiencing moderate anxiety can be redirected when instructed to do so.

The school-aged children of a deployed marine are engaging in physical fighting to solve problems with each other at home. The nurse helps minimize this situation best by: assessing when the problem with aggressive behavior first began. asking the children to discuss why they fight with each other so often. helping the parent establish fair punishments for fighting that are consistently applied. providing the parent with opportunities to use new strategies for managing aggression.

A stress-laden patient has elected to learn deep breathing as a means of reducing stress. Rank the following statements in the order in which the nurse should give information when teaching this technique. (Separate letters by a comma and space as follows: A, B, C, D.) a. "Focus on your breathing; repeat the exercise for 2 to 5 minutes." b. "With each breath, pay attention to muscular sensations that accompany abdominal expansion." c. "Hold the breath for 3 seconds." d. "Find a comfortable position. Relax the shoulders and chest; let the body relax." e. "Take a deep breath through the nose, expanding the abdomen." f. "Exhale slowly through the nose, telling the body to relax."

Final exam Nurs351

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