Final Study Guide

The nurse prepares a client who's 28 weeks pregnant for a nonstress test (NST). Which intervention is likely to stimulate fetal movements during this test?

"1. Having the client drink orange juice

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider (HCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the HCP has documented the results as negative. How should the nurse interpret this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery

1. A normal test result

The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of: A. Uterine contractions occurring every 8 to 10 minutes. B. Rupture of the client's amniotic membranes. C. A fetal heart rate (FHR) of 180 with absence of variability. D. The client's needing to void.

A fetal heart rate (FHR) of 180 with absence of variability

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? A. At the beginning of each fetal movement B. At the beginning of each contraction C. After every three fetal movements D. At the end of fetal movement

A. At the beginning of each fetal movement

Tylenol (Acetaminophen)

Analgesic; Antipyretic; liver toxicity with high doses; <4000mg/day; liver patient <2000mg/day Antidote: acetylcysteine (Mucomyst)

Plavix

Anticoagulant, Given to patients with increase risk of DVT Monitor the PLT count *Normal PLT count: 150,000-400,000

Heparin

Anticoagulant;Monitor pt's lab work-PTT. Antidote is protamine sulfate

The nurse assists the physician during paracentesis. In which position does the nurse place the client? a) lying position b) sitting position c) prone position d) side-lying position

B paracentesis is aspiration of fluid from the abdominal cavity. Sitting position allows fluid to settle at lower abdomen. This facilitates aspiration of fluids.

The client asks what the difference is between dalteparin (Fragmin) and heparin. What is the nurse's best response? A) a. "There is no real difference. Dalteparin is preferred because it is less expensive." B) b. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding." C) c. "I'm not sure why some health care providers choose dalteparin and some heparin. You should ask your doctor." D) d. "The only difference is that heparin dosing is based on the client's weight."

B. A low-molecular-weight heparin is more predictable in its effect than regular heparin. Dalteparin (Fragmin) is more expensive than heparin and is dosed based on the client's

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? a. "You should call the doctor if pain or herpes lesions occur near the ear." b. "Treatment of herpes with antiviral agents will prevent development of Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "You may be able to prevent Bell's palsy by doing facial exercises regularly."

Correct Answer: A Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy. Cognitive Level: Application Text Reference: p. 1585 Nursing Process: Implementation NCLEX: Physiological Integrity

the nurse is reviewing the home medication list for a 44-year-old man admitted with suspected hepatic failure. Which medication could cause hepatotoxicity? A. Nitroglycerin B. Digoxin (Lanoxin) C. Ciprofloxacin (Cipro) D. Acetaminophen (Tylenol)

D. Acetaminophen (Tylenol)

Two medications used to treat neurogenic shock are? A. Carvedilol and digoxin B. Dopamine and dobutamine C. Albuterol and epinephrine D. Miralax and hydrocodone

Dopamine and dobutamine

What is an indicator for performing a contraction stress test? D. Increased fetal movement and small for gestational age E. Maternal diabetes mellitus and postmaturity F. Adolescent pregnancy and poor prenatal care G. History of preterm labor and intrauterine growth restriction

E. Maternal diabetes mellitus and postmaturity

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? Headache and rising blood pressure Irregular respirations and shortness of breath Decreased level of consciousness or hallucinations Abdominal distention and absence of bowel sounds

Headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.

The priority nursing care associated with an oxytocin (Pitocin) infusion is: Monitoring uterine response. Increasing infusion rate every 30 minutes. Measuring urinary output. Evaluating cervical dilation.

Monitoring uterine response.

Know the high risk patients when treating chronic hepatitis with drugs

Patients who have advanced fibrosis or cirrhosis can be treated with drug therapy as long as liver decompensation (e.g., ascites, esophageal hemorrhage, jaundice, wasting, encephalopathy) is not present.

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome

Spinal shock syndrome About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

Evaluation markers for the effectiveness of oxytocin inductions

The goal of oxytocin administration is to produce acceptable uterine contractions as evidenced by: • Consistent achievement of 200 to 220 MVUs or • A consistent pattern of one contraction every 2 to 3 minutes, lasting 80 to 90 seconds, and strong to palpation

In an acute injury setting, neurogenic shock is commonly accompanied by: A) hypovolemia. B) diaphoresis. C) tachycardia. D) hypothermia.

hypothermia

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery

1. A normal test result

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? 1. Normal 2. Abnormal 3. The need for further evaluation 4. That findings were difficult to interpret

1. Normal

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result? 1. Normal findings 2. Abnormal findings 3. The need for further evaluation 4. That the findings on the monitor were difficult to interpret

1. Normal findings

A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for: 1 Hypertensive crisis 2 Hypovolemic shock 3 Abdominal distention 4 Tenting of the integument

2. Hypovolemic shock

A client in week 35 of her pregnancy is placed on the fetal heart monitor (FHM) for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes what conclusion regarding the NST? 1. The fetal heart rate (FHR) is positive, with a baseline of 130 beats/min, moderate variability, and no decelerations. 2. The FHR is reactive, with a baseline of 130 beats/min, moderate variability, and no decelerations. 3. The FHR is nonreactive, with a baseline of 130 beats/min, moderate variability, and small episodic decelerations. 4. The FHR is negative, with a baseline of 130 beats/min, moderate variability, and no decelerations.

2. The FHR is reactive, with a baseline of 130 beats/min, moderate variability, and no decelerations.

The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action? 1. Notify the health care provider. 2. Prepare the client for labor induction. 3. Place the fetal heart monitor on the client in order to do a nonstress test (NST). 4. Provide the client with information regarding warning signs and symptoms of pregnancy and discharge her to home.

3. Place the fetal heart monitor on the client in order to do a nonstress test (NST).

A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? 1. "The test is a procedure that will require an informed consent to be signed." 2. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 3. "The test is done to see if the baby can handle the stress of labor, and that medicine is given to make the uterus contract." 4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen."

4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen."

A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client? 1. "The test is an invasive procedure and requires that you sign an informed consent." 2. "The fetus is challenged by uterine contractions to obtain the necessary information." 3. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

A patient with cancer of the liver has severe ascites, and the health care provider plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, the nurse a. asks the patient to empty the bladder. b. positions the patient on the right side. c. obtains informed consent for the procedure. d. assists the patient to lie flat in bed.

A Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. The health care provider is responsible for obtaining informed consent

The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? A Progressive leg exercises to obtain 90-degree flexion B Early ambulation with full weight bearing on the left leg C Bed rest for 3 days with the left leg immobilized in extension D Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

A Progressive leg exercises to obtain 90-degree flexion Although early ambulation is not done, the patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the patient requires good pain management and often the use of a CPM machine. The patient's knee is unlikely to dislocate.

The nurse performs discharge teaching for a 34-year-old male patient with a T2 spinal cord injury resulting from a construction accident. Which statement, if made by the patient to the nurse, indicates that teaching about recognition and management of autonomic dysreflexia is successful? A. "I will perform self-catheterization at least six times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."

A. "I will perform self-catheterization at least six times per day." Autonomic dysreflexia is usually caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? A. Administration of blood B. Preparation of the woman for invasive hemodynamic monitoring C. Restriction of intravascular fluids D. Administration of steroids

A. Administration of blood Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement (not volume restriction), blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because it could contribute to more areas of bleeding. Steroids are not indicated for the management of DIC.

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At present she is at the greatest risk for: A. Hemorrhage. B. Infection. C. Urinary retention. D. Thrombophlebitis.

A. Hemorrhage. Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention or thrombophlebitis than does a normally implanted placenta.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? A. Transition labor with contractions every 2 minutes, lasting 90 seconds each. B. Early labor with contractions every 5 minutes, lasting 40 seconds each. C. Active labor with contractions every 31 minutes, lasting 60 seconds each. D. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each.

A. Transition labor with contractions every 2 minutes, lasting 90 seconds each.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate? A.Grief related to her perceptions about the loss of this child. B.Relief of ambivalent feelings experienced with this pregnancy. C.Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions.

A.Grief related to her perceptions about the loss of this child.

36. A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT? a. New ST segment elevation is noted on the cardiac monitor. b. Enteral feedings are being given through an orogastric tube. c. Scattered rhonchi are heard when auscultating breath sounds. d. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.

ANS: A Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. The other information will also be shared with the health care provider, but ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used.

22. A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The heart rate is 58 beats/minute. c. The stroke volume is increased. d. The stroke volume variation is 12%.

ANS: A The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation.

33. A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion.

ANS: A The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient's anxiety.

With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that: a.Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. b.Hydramnios occurs approximately twice as often in diabetic pregnancies. c.Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies. d.Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.

ANS: A Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild to moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: a.Frequent episodes of maternal hypoglycemia. b.Congenital anomalies in the fetus. c.Polyhydramnios. d.Hyperemesis gravidarum.

ANS: B Congenital anomalies in the fetus. Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: a.With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. b.The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. c.Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. d.At birth the neonate of a diabetic mother is no longer in any risk.

ANS: B The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. Congenital malformations account for 30% to 50% of perinatal deaths. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.

20. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem? a. Increase suctioning to every hour. b. Reposition the patient every 1 to 2 hours. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.

ANS: C Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

18. The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which action by the nurse is a priority? a. Decrease the suction pressure to 80 mm Hg. b. Document the dysrhythmia in the patient's chart. c. Stop and ventilate the patient with 100% oxygen. d. Give antidysrhythmic medications per protocol.

ANS: C Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated.

19. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient's oxygen saturation is 93%. b. The patient was last suctioned 6 hours ago. c. The patient's respiratory rate is 32 breaths/minute. d. The patient has occasional audible expiratory wheezes.

ANS: C The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed

24. The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is 58 beats/minute. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

ANS: C Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion.

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that: a.Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b.Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. c.During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d.Maternal insulin requirements steadily decline during pregnancy.

ANS: C During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin around the tenth week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.

37. After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring c. Patient with a central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP) d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

ANS: D The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.

32. The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to reposition the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.

ANS: D The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate.

17. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation.

ANS: D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

30. The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

ANS: D The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient's oxygenation

21. Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. increase the tidal volume. c. increase the respiratory rate. d. decrease the respiratory rate.

ANS: D The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.

A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)? a.75 mg/dL before lunch. This is low; better eat now. b.115 mg/dL 1 hour after lunch. This is a little high; maybe eat a little less next time. c.115 mg/dL 2 hours after lunch; This is too high; it is time for insulin. d.60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.

ANS: D 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep. 60 mg/dL after waking from a nap is too low. During hours of sleep glucose levels should not be less than 70 mg/dL. Snacks before sleeping can be helpful. The premeal acceptable range is 65 to 95 mg/dL. The readings 1 hour after a meal should be less than 140 mg/dL. Two hours after eating, the readings should be less than 120 mg/dL.

"Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? "1) ""I will not drink any type of beer or mixed drink."" 2)""I will get adequate rest so I don't get exhausted."" 3) ""I had a big hearty breakfast this morning."" 4) ""I took some cough syrup for this nasty head cold.""

Answer 4: "Rationale: 1) The client should avoid all alcohol to prevent further liver damage and promote healing. 2) Rest is needed for healing of the liver and to promote optimum immune function. 3) Clients with hepatitis need increased caloric intake so this is a good statement. 4)The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention"

A client has been admitted through the emergency department and requires emergency surgery. The client has been receiving heparin. What nursing intervention is essential? A) a. Teach the client about the phenytoin. B) b. Administer protamine sulfate. C) c. Assess the INR before surgery. D) d. Administer vitamin K.

B. Protamine sulfate binds with heparin in the bloodstream to inactivate it and thus reverse its effect.

A client is receiving an intravenous heparin drip. Which laboratory value will require immediate action by the nurse? A) a. Platelet count of 150,000 B) b. Activated partial thromboplastin time (aPTT) of 120 seconds C) c. INR of 1.0 D) d. Blood urea nitrogen (BUN) level of 12 mg/dL

B. This aPTT value is too prolonged. The heparin drip should be shut off for an hour.

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: A. Bleeding. B. Intense abdominal pain. C. Uterine activity. D. Cramping.

B. Intense Abd Pain Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding, uterine activity, and cramping may be present in varying degrees for both placental conditions.

During rounds, a nurse suspects that a patient who has recently delivered via vaginal route is having excessive postpartum bleeding. Which intervention would be the priority action taken by the nurse at this time? A. Call the physician. B. Massage the uterine fundus. C. Increase the rate of intravenous fluids. D. Monitor pad count and perform catheterization.

B. Massage the uterine fundus. Massaging of the uterine fundus would be a priority action to help expel clots and stimulate uterine contractions to constrict blood flow. The other actions described, as well as catheterization (if bladder distention is noted) and lochia flow monitoring, may be needed, but none of them is the priority action required at this time.

You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome

B. Spinal shock syndrome About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

One month after a spinal cord injury, which finding is most important for you to monitor? A. Bladder scan indicates 100 mL. B. The left calf is 5 cm larger than the right calf. C. The heel has a reddened, nonblanchable area. D. Reflux bowel emptying.

B. The left calf is 5 cm larger than the right calf. Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.

A multigravida client at 41 weeks gestation presents in the labor and delivery unit after a non stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? A. Biophysical Profile B. Ultrasound for fetal anomalies C. Maternal Serum Alpha Fetaprotein (AF) Screening D. Percutaneous Umbilical Blood Sampling (PUBS)

Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate.

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses

Bradycardia Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 78-year-old patient following left total knee replacement. What would be an appropriate nursing intervention for this patient? A Promote vitamin C and calcium intake in the diet. B Provide passive range of motion to all of the joints q4hr. C Encourage isometric quadriceps-setting exercises at least qid. D Keep the left leg in extension and abduction to prevent contractures.

C Encourage isometric quadriceps-setting exercises at least qid. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery along with a continuous passive motion (CPM) machine. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to do active range of motion to all joints. Keeping the leg in one position (extension and abduction) potentially will result in contractures.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A) the pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. B) two thirds of newborns with fetal alcohol syndrome (FAS) are boys. C) alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. D) Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

C) alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. Rationale: Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

A nurse is preparing to administer enoxaparin sodium (Lovenox) [LMWH heparin] to a client for prevention of deep vein thrombosis. What is an essential nursing intervention? A) a. Draw up the medication in a syringe with a 22-gauge, 1-½ inch needle. B) b. Utilize the Z-track method to inject the medication. C) c. Administer the medication into subcutaneous tissue. D) d. Rub the administration site after injecting

C. Enoxaparin (Lovenox) is a low-molecular-weight heparin that is administered subcutaneously

Which nursing diagnosis would be possible for a client receiving intravenous heparin therapy? A) a. Potential for fluid volume excess B) b. Potential for pain C) c. Risk for injury D) d. Potential for body image disturbance

C. The client receiving heparin is at risk for injury secondary to increased risk of bleeding

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? A. "It is safe to take acetaminophen up to four times a day for pain." B. "Lactulose (Cephulac) should be taken every day to prevent constipation." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."

C. "Herbs and other spices should be used to season my foods instead of salt."

What differentiates neurogenic shock from other types of shock? A. Hypertension B. Tachypnea C. Bradycardia D. Hyperbilirubin

C. Bradycardia

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. Von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels rise naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks postpartum as levels of von Willebrand factor (vWf) and factor VIII fall. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is: A. Cryoprecipitate B. Factor VIII and vWf C. Desmopressin D. Hemabate

C. Desmopressin

What is the classic manifestation of a spinal cord tumor? A. Sudden onset of excruciating pain, worse at night B. Radiating pain down one leg C. Gradual onset of radicular pain, worse when lying down D. Positive Brudzinski's sign

C. Gradual onset of radicular pain, worse when lying down Tumors are slow growing. The most common early symptom is pain in the back with radicular pain. The pain worsens with activity, coughing, straining, and lying down. Sudden onset of excruciating pain is not related to spinal cord tumors. Radiating pain down one leg is a classic characteristic of sciatic nerve pathology. A positive Brudzinski's sign is seen in meningitis.

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A. Sometimes uses vibroacoustic stimulation. B. Is an invasive test; however, contractions are stimulated. C. Is considered to have a negative result if no late decelerations are observed with the contractions. D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.

C. Is considered to have a negative result if no late decelerations are observed with the contractions. Rationale: Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is by IV oxytocin but not if by nipple stimulation. No late decelerations indicate a positive CST. CST is contraindicated if the membranes have ruptured.

Which indicator would lead the nurse to suspect that a postpartum patient experiencing hemorrhagic shock is getting worse? A. Restoration of blood pressure levels to normal range B. Capillary refill brisk C. Patient complaint of headache and increased reaction time to questioning D. Patient statement that she sees "stars"

C. Patient complaint of headache and increased reaction time to questioning Patient complaint of a headache accompanied by an increased reaction (response) time indicates that cerebral hypoxia is getting worse. Return of blood pressure to normal range would indicate resolving symptoms. Brisk capillary refill is a normal finding. The patient may see "stars" early on in decreased blood flow states.

What is most important action for a patient who has a suspected cervical spinal injury? A. Apply a soft foam cervical collar. B. Perform a neurologic check. C. Place the patient on a firm surface. D. Assess function of cranial nerves IX and X.

C. Place the patient on a firm surface. A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface. This takes priority over any further assessment. A soft foam collar does not provide immobilization.

Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion? A. Prepare the woman for a dilation and curettage (D&C). B. Put the woman on bed rest for at least 1 week and reevaluate. C. Prepare the woman for an ultrasound and blood work. D. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month.

C. Prepare the woman for an ultrasound and blood wo Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine whether the fetus is alive and within the uterus. Bed rest is recommended for 48 hours initially. D&C is not considered until signs of the progress to inevitable abortion are noted or the contents are expelled and incomplete. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.

Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)? A. Scheduled prophylactic nasopharyngeal suctioning B. Instilling normal saline down the endotracheal tube to loosen secretions C. Providing frequent mouth care and oral hygiene D. Using high tidal volumes on the ventilator

C. Providing frequent mouth care and oral hygiene A frequent complication of ARDS is ventilator-associated pneumonia. Preventative strategies include elevating head-of-bed 30-45 degrees and strict infection control measures such as frequent hand washing, use of in-line suction, and frequent mouth care and oral hygiene. Suctioning is done only as needed to prevent stimulating excess secretions. Instilling normal saline does not loosen secretions and can cause hypoxia. It is not recommended. High tidal volumes can lead to barotrauma.

A woman presents to the emergency department complaining of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary health care provider finds that the cervix is closed. The anticipated plan of care for this woman is based on a probable diagnosis of which type of spontaneous abortion? A. Incomplete B. Inevitable C. Threatened D. Septic

C. Threatened A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. Heavy bleeding, mild to severe cramping, and cervical dilation are the presentation for both incomplete abortion and inevitable abortion. A woman with a septic abortion presents with malodorous bleeding and, typically, a dilated cervix.

The nurse is caring for a client with cirrhosis of the liver. The client has developed ascites and requires a paracentesis. Which of the following symptoms is associated with ascites and should be relieved by the paracentesis? A. Pruritus. B. Dyspnea. C. Jaundice. D. Peripheral neuropathy.

Correct answer: B Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm, resulting in difficulty breathing and dyspnea. Paracentesis (surgical puncture of the abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and thus reduce pressure on the diaphragm in order to relieve the dyspnea. Pruritus, jaundice, and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by paracentesis.

A client is hospitalized with hepatitis A. Which of the client's regular medications is contraindicated due to the current illness? http://www.rnpedia.com/home/exams/nclex-exam/nclex-rn-practice-questions-6 "1. Prilosec (omeprazole) 2. Synthroid (levothyroxine) 3. Premarin (conjugated estrogens) 4. Lipitor (atorvastatin)

Correct: 4 Lipitor (atorvastatin) Lipid-lowering agents are contraindicated in the client with active liver disease. Answers A, B, and C are incorrect because they are not contraindicated in the client with active liver disease.

This morning a 21-year-old male patient had a long leg cast applied and wants to get up and try out his crutches before dinner. The nurse will not allow this. What is the best rationale that the nurse should give the patient for this decision? A The cast is not dry yet, and it may be damaged while using crutches. B The nurse does not have anyone available to accompany the patient. C Rest, ice, compression, and elevation are in process to decrease pain. D Excess edema and other problems are prevented when the leg is elevated for 24 hours

D Excess edema and other problems are prevented when the leg is elevated for 24 hours For the first 24 hours after a lower extremity cast is applied, the leg will be elevated on pillows above the heart level to avoid excessive edema and compartment syndrome. The cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new order to be "up in chair today before noon." What action should the nurse take to protect the knee joint while carrying out the order? A Administer a dose of prescribed analgesic before completing the order. B Ask the physical therapist for a walker to limit weight bearing while getting out of bed. C Keep the continuous passive motion machine in place while lifting the patient from bed to chair. D Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting.

D Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting. The nurse should apply a knee immobilizer for stability before assisting the patient to get out of bed. This is a standard measure to protect the knee during movement following surgery. Although an analgesic should be given before the patient gets up in the chair for the first time, it will not protect the knee joint. Full weight bearing is begun before discharge, so a walker will not be used if the patient did not need one before the surgery. The CPM machine is not kept in place while the patient is getting up to the chair.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency to every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: A. Eclamptic seizure. B. Rupture of the uterus. C. Placenta previa. D. Placental abruption.

D. Placental Abruption Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests with hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain, and placenta previa with bright red, painless vaginal bleeding.

You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache

D. Throbbing headache Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system, which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? A. Determine if the patient lost consciousness. B. Assess the Glasgow Coma Scale (GCS) score. C. Obtain a set of vital signs. D. Use a logroll technique when moving the patient.

D. Use a logroll technique when moving the patient. When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.

The oxygen delivery system chosen for the patient in acute respiratory failure should A. always be a low-flow device, such as a nasal cannula. B. correct the PaO2 to a normal level as quickly as possible. C. administer positive-pressure ventilation to prevent CO2 narcosis. D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible

D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible. The selected oxygen delivery system must maintain PaO2 at 55 to 60 mm Hg and SaO2 at 90% or greater at the lowest oxygen concentration possible.

A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation? Prevent urinary tract infections. Monitor the patient every 15 minutes. Encourage him to verbalize his feelings. Teach him about using the gastrocolic reflex.

Encourage him to verbalize his feelings. To help him with his coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages his self-expression and verbalization of thoughts and feelings. This patient is at high risk for depression and self-injury because he is likely to lose function below the umbilicus involving lost motor and sensory function. In addition, he is a young adult male patient who is likely to need a wheelchair, have impaired sexual function, and is unlikely to resume his racing career. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits that can make coping especially difficult for him. Prevention of urinary tract infections and facilitating bowel evacuation with the gastrocolic reflex will be important but not as important as helping him cope. In rehabilitation, monitoring every 15 minutes is not needed unless he is on a suicide watch.

Lab marker for DIC

Laboratory Coagulation Screening Test Results • Platelets—decreased • Fibrinogen—decreased • Factor V (proaccelerin)—decreased • Factor VIII (antihemolytic factor)—decreased • Prothrombin time—prolonged • Activated partial thromboplastin time—prolonged • Fibrin degradation products—increased • D-dimer test (specific fibrin degradation fragment)—increased • Red blood smear—fragmented red blood cells Physical Examination Findings • Spontaneous bleeding from gums, nose • Oozing, excessive bleeding from venipuncture site, intravenous access site, or site of insertion of urinary catheter • Petechiae (e.g., on the arm where blood pressure cuff was placed) • Other signs of bruising • Hematuria • Gastrointestinal bleeding • Tachycardia • Diaphoresis

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? A. Your current dose of insulin should be maintained throughout your pregnancy. B. Maintaining blood sugar within a normal range during pregnancy has a strong correlation with a good outcome. Insulin requirements normally change during pregnancy. C. The course and outcome of your pregnancy is not an achievable goal with diabetes D. Expect an increase in insulin dosages by 5 units/week during the first trimester.

Maintaining blood sugar within a normal range during pregnancy has a strong correlation with a good outcome. Insulin requirements normally change during pregnancy.

A 19-year-old man is admitted to the emergency department with a C6 spinal cord injury after a motorcycle crash. Which medication should the nurse anticipate that she will administer first? A. Enoxaparin (Lovenox) B. Metoclopramide (Reglan) C. IV immunoglobulin (Sandoglobulin) D. Methylprednisolone sodium succinate (Solu-Medrol)

Methylprednisolone sodium succinate (Solu-Medrol) Methylprednisolone (MP) blocks lipid peroxidation by-products and improves blood flow and reduces edema in the spinal cord. High-dose MP should be administered within 8 hours of injury. Enoxaparin is a low-molecular-weight heparin used to prevent deep vein thrombosis. Metoclopramide is used to treat delayed gastric emptying. IV immunoglobulin (Sandoglobulin) is used to treat Guillain-Barré syndrome.

Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? Urinary catheterization Administration of benzodiazepines Suctioning of the patient's upper airway Placement of the patient in the Trendelenburg position

Urinary catheterization Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. Benzodiazepines are contraindicated, and suctioning is likely unnecessary. The patient should be positioned upright.

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: a.Macrosomia. b.Congenital anomalies of the central nervous system. c.Preterm birth. d.Low birth weight.

a. Macrosomia. Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman.

A nurse is caring for a pt who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects air emobolism and clamps the catheter immediately. The nurse should reposition the pt in which of the following positions? a) supine with pillow beneath the knees b) on his left side in trendelenburg position c) upright and leaning over the overbed table d) on his right side with the head of the bed elevated 15 degrees

b) on his left side in trendelenburg position This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and, from there, move to the pulmonary arterial system

In terms of the incidence and classification of diabetes, maternity nurses should know that: a.Type 1 diabetes is most common. b.Type 2 diabetes often goes undiagnosed. c.Gestational diabetes mellitus (GDM) means that the woman will be receiving insulin treatment until 6 weeks after birth. d.Type 1 diabetes may become type 2 during pregnancy.

b.Type 2 diabetes often goes undiagnosed. Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2 diabetes, sometimes called adult onset diabetes, is the most common. GDM refers to any degree of glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do not go back and forth between types 1 and 2 diabetes.

The nurse is teaching a client about clopidogrel (Plavix). What is important information to include? a. Constipation may occur. b. Hypotension may occur. c. Bleeding may increase when taken with aspirin. d. Normal dose is 25 mg tablet per day.

c. Bleeding may increase when taken with aspirin.

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a.call the physician. b.check the patient's temperature. c.take the patient's blood pressure. d.elevate the head of the bed to 90 degrees.

c.take the patient's blood pressure.

A nurse is preparing to obtain a blood sample from a pt who has a triple-lumen central catheter in place for multiple therapies. which of the following is an appropriate action for the nurse to take? a) Discard the first 15 mL of aspirated blood before collecting the sample b) Maintain the pt in Trendelenburg position while withdrawing the blood sample c) Withdraw the blood sample from the lumen that has the smallest diameter d) Turn of f the distal infusions for 1-5 mins before obtaining the blood sample

d) turn off the distal infusions To help ensure that the laboratory results won't be altered by the solutions infusing through the central access device, it is recommended that the nurse stop the distal infusions and clamp the tubing for 1-5 mins before obtaining the blood sample

3. In planning for the care of a 30year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: a.Mother's age. b.Number of years since diabetes was diagnosed. c.Amount of insulin required prenatally. d.Degree of glycemic control during pregnancy.

d. Degree of glycemic control during pregnancy.

Which arterial blood gas (ABG) results would most likely indicate acute respiratory failure in a patient with chronic lung disease? a. PaO2 52 mm Hg, PaCO2 56 mm Hg, pH 7.4 c. PaO2 48 mm Hg, PaCO2 54 mm Hg, pH 7.38 b. PaO2 46 mm Hg, PaCO2 52 mm Hg, pH 7.36 d. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28

d. In a patient with normal lung function, respiratory failure is commonly defined as a PaO2 ≤60 mm Hg or a PaCO2 >45 mm Hg or both. However, because the patient with chronic pulmonary disease normally maintains low PaO2 and high PaCO2 , acute respiratory failure in these patients can be defined as an acute decrease in PaO2 or an increase in PaCO2 from the patient's baseline parameters, accompanied by an acidic pH. The pH of 7.28 reflects an acidemia and a loss of compensation in the patient with chronic lung disease.

A client with acute hepatitis is prescribed lactulose. The nurse knows this medication will: "a. Mobilize iron stores from the liver. b. Prevent hypoglycemia c. Remove bilirubin from the blood d. Prevent the absorption of ammonia from the bowel.

d. Prevent the absorption of ammonia from the bowel. Correct D Lactulose helps prevent the absorption of ammonia from the bowel because it will cause frequent bowel movements, which facilitates the removal of ammonia from the intestines.

A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. On physical examination, the nurse would most likely find a.upper extremity weakness only. b.complete motor and sensory loss below C7. c.loss of position sense and vibration in both lower extremities. d.ipsilateral motor loss and contralateral sensory loss below C7.

d.ipsilateral motor loss and contralateral sensory loss below C7.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 84/50 mm Hg, his pulse is 38 beats/minute, and he remains orally intubated. The nurse determines that this pathophysiologic response is caused by a.increased vasomotor tone after injury.b. a temporary loss of sensation and flaccid paralysis below the level of injury. c.loss of parasympathetic nervous system innervation resulting in vasoconstriction. d.loss of sympathetic nervous system innervation resulting in peripheral vasodilation.

d.loss of sympathetic nervous system innervation resulting in peripheral vasodilation.

Clinical manifestations of FAS...(8)

small for gestational age epicanthal folds (facial features) maxillary hypoplasia (facial features) long and thin upper lip (facial features) hyperactive HIGH pitched cry poor feeding persistent vomiting