Health and Illness test 1

A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 3g/h with normal saline to maintain the total IV rate at 125mL/hr. The nurse giving the end of shift report states the client's blood pressures have been elevated during the night. the oncoming nurse check the client and found the magnesium sulfate running at 2g/h. identify the nursing actions to be taken from first to last. all options must be used.

1. assess the client's current status 2. correct the IV rates 3. Notify the primary health care provider of the incident 4. initiate an incident report

a 40 year old patient has completed radiation therapy for testicular cancer tells the nurse that he is unable to achieve erection. which response is most appropriate? a. "sexual dysfunction can be a side effect of radiation therapy. would you like to talk about it?" b. "impotence after testicular cancer is permanent. There are other ways to help you achieve erection." c. "impotence can result from improper nutrition after radiation, we could have you see the dietitian." d. "your body is just protecting itself. This impotence will subside as soon as your body has recovered fromt therapy."

a. "sexual dysfunction can be a side effect of radiation therapy. would you like to talk about it?"

A client is in the first stage of labor. She asks the nurse how to promote labor progression and efficient uterine contractions. What response by the nurse is most appropriate. a. "the best option at this stage is to ambulate." b. "lying supine will conserve energy for the second stage of labor." c. "any position, but ensure infrequent position changes if possible." d. "lying on your side without the use of pillows."

a. "the best option at this stage is to ambulate."

The nurse is obtaining a sexual history from an adolescent patient. Which finding has the greatest implication for the patient's care? a. Patient has been intimate with more than one person in the last year b. Patient states that he/she is in a monogamous relationship c. patient denies any sexual activity d. patient states that he/she uses "safe sex" practices

a. Patient has been intimate with more than one person in the last year

an adult patient come for a well check up to the primary care providers office. in completing the office admission form, the patient does not indicate gender on the form and seems somewhat agitated when providing the form back to the nurse. how should the nurse respond? a. ask the patient if you can assist with completing the form b. tell the patient the doctor requires the form to be completed before seeing the patient. c. ask the patient to complete all of the information at this time d. the nurse should accept the form and indicate what gender she/he thinks is appropriate

a. ask the patient if you can assist with completing the form

which nursing intervention will be included in the plan of care for a patient with ITP? a. avoid IM and SC injections b. restrict activity to passive and active rang of motion c. place patient in a private room d. use rinses than a soft toothbrush for oral care

a. avoid IM and SC injections

A nurse is completing a prenatal assessment on a woman who is 28 weeks pregnant with gestational hypertension. which findings should be reported to the primary care provider? select all that apply a. dull headache b. weight gain of one pound in a week c. blurred vision d. 1+ urine protein e. fundal height of 28 cm

a. dull headache c. blurred vision d. 1+ urine protien

upon assessment, which of the following findings would the nurse expect to find a child with ITP a. epistaxis and petechia b. leukocytosis and hemolysis c. decreased PT/PTT d. mottling on hands and feet

a. epistaxis and petechia

for a client newly diagnosed with radiation induced thrombocytopenia, the nurse should include which intervention in the plan of care? a. inspect the skin for petechiae at least once every shift. b. administer aspirin if the temp exceeds 100.5 c. provide for frequent rest period d. place the client in contact isolation

a. inspect the skin for petechiae at least once every shift.

For a patient with deep vein thrombosis (DVT), the nurse would include in the plan of nursing care the intervention: a. keep affected leg elevated b. restricting fluids c. applying cool compresses to the area d. keep affected leg in the dependent position

a. keep affected leg elevated

a one week post partum calls the nurse line. she describes symptoms of discomfort, erythema and swelling to her left calf. what post partum complication is the call center RN most concerned for in this patient? a.deep vein thrombosis b. post partum eclampsia c. venous variosity d. venous stasis

a.deep vein thrombosis

the nurse is caring for a client in active labor. the client states "i feel like i need to push." A sterile vaginal examination reveals that the client is dilated to 8cm. what is the nurses best response? a. "you cannot push yet, you have another 2cm until you are ready." b. "your cervix is not fully dilated. let's keep breathing through the pressure." c. " go ahead and push just a little when you feel the urge." d. "I will get you some IV pain medication to take the edge off."

b. "your cervix is not fully dilated. let's keep breathing through the pressure."

a primigravida patient - hypertensive 24th weeks of pregnancy. she presents 30 weeks gestation, bp is 142/94. protein urine 3+, glucose of 97, platelet count of 95,000 with elevated AST and ALT levels, nausea and vomiting and epigastric pain. a. gestational diabetes b. HELLP c. DIC d. Rh compatibility

b. HELLP

the most intense time during labor is during the a. latent phase b. active phase c. membrane breaking d. placental explusion phase

b. active phase

a client in her 15th week of pregnancy has presented with abdominal cramping and bright red vaginal bleeding for the past 2 hours. she has passed several clots. what is the priority nursing care? a. prepare for surgery b. assess the maternal vital signs c. asses the fetal heart rate d. obtain hemoglobin and hematocrit

b. assess the maternal vital signs

which of the following lab test results would the nurse expect to find in a pregnant woman with DIC? a. increased fibrinogen level b. elevated d-dimer c. shortened prothrombin time

b. elevated d-dimer

which of the following statements about heparin is true? a. it can be affected by a diet high in vit K b. its antagonist is protamine sulfate c. it has an unpredictable duration of action d. it can be administered by mouth

b. its antagonist is protamine sulfate

A nursery nurse performing the first physical assessment of the newborn observes there is no clear identification of genitalia as being either female or male. How should the nurse identify this newborn? a. asexual b. observation of intersex c. bisexual d. gender neutral

b. observation of intersex

a patient admitted to the hospital in preparation for a splenectomy for treatment of ITP asks the nurse about the benefits of the splenectomy. the nurse explains the effect of splenectomy is a. promotion of platelet sequestion and release by the liver b. reduced destruction of platelets by macrophages c. increase production of platelets by the bone marrow d. increased RBC production to compensate for blood loss

b. reduced destruction of platelets by macrophages

the nurse is instructing a client who will be discharged on anticoagulant therapy. what is the most important instruction for this nurse to include? a. do not shave with an electric razor b. take the anticoagulant at the same time each day c. take ibuprofen or aspirin for pain d. eat green, leafy vegetables and salad daily

b. take the anticoagulant at the same time each day

a client with atrial fibrillation is prescribed warfarin. how should the nurse explain the purpose of this medication to the client? a. "this medication is prescribed to help manage the irregular heart rhythm from atrial fibrillation." b. warfarin thinks your blood, making it easier for your heart to pump to your body." c. "warfarin is prescribed to people with atrial fibrillation to reduce the risk of having a stroke or PE." d. "warfarin is a blood thinner, which puts you at an increased risk for bleeding."

b. warfarin thinks your blood, making it easier for your heart to pump to your body."

vaginal examination of a patient in labor reveals that the presenting part of the fetus is at the level of maternal ischial spines. the nurse documents this finding as a. +2 station b. -2 station c. 0 station d. crowning

c. 0 station

Using Nageles rule to determine the EDC/EDD of the primpara client stating the first day of her LMP was 2/28/21. select the correct answer below a. 11/28/22 b. 12/28/21 c. 12/5/21 d. 12/5/22

c. 12/5/21

A 62- year old woman asks the nurse what she can do to promote healthy sexual relationship with her husband. based on the patient's age, the nurse could best respond by saying: a. "Reducing the frequency of intercourse is a normal response for couples when they get to your age." b. "I can refer you to a sexual therapist to assist you to get a more satisfying relationship." c. Sometimes as you age, use of a water-based lubricant will make intercourse more comfortable." d. "Continue doing what you have- age does not really change the sexual relationship."

c. Sometimes as you age, use of a water-based lubricant will make intercourse more comfortable."

as the RN in busy obstetric clinic, you are coordinating the care for dawn. she has been hypertensive since her 24th week of pregnancy and today her blood pressure is 142/94. urinalysis indicates a protein content of 3+. further testing reveals a platelet count of 95,000 and the elevated AST and ALT levels: shes has begun to experience nausea with some vomiting and epigastric pain. with what orders do you anticipate receiving from the obstetrician. a. admit patient to the OB unit for observation status. monitor fetal heart tones and LFT every 6 hours b.send patient home with an increased dosage of hydralazine and return to clinic tomorrow c. admit the patient to OB to prepare for patient stabilization and delivery of baby d. send patient to the OB triage to monitor feta heart tone for 3 hours

c. admit the patient to OB to prepare for patient stabilization and delivery of baby

which of the following clinical findings would alert the nurse to the development of a lower extremity DVT in the patient? a. pallor in the affected extremity b. unilateral edema in affected extremity c. affected extremity cool to touch d. temp of 100

c. affected extremity cool to touch

A patient comes into the clinic complaining of sexual dysfunction. The nurse should investigate the patient's medication. Which one of the following groups of medication are known to cause sexual dysfunction. a. antibiotics b. non-steriod anti-inflammatory c. antihypertensive d. bronchodilators

c. antihypertensive

which assessment finding indicates that the multiparous patient in the transitional phase of the first stage of labor? a. contractions hard by palpation b. cervix dilated to 6cm and 60% effaced c. contractions occurring every 5- 10 minutes and lasting approximately 60 seconds d. fetal presenting part at the -1 station

c. contractions occurring every 5- 10 minutes and lasting approximately 60 seconds

a patient is diagnosed with primary syphillis (stage 1). when assessing the patient, which findings would the nurse anticipate? a. reddish rash on the palms of the hands b. sore throat and swollen lymph glands c. firm and painless genital ulcer d. muscle weakness and visual changes

c. firm and painless genital ulcer

which sign/symptom should lead the nurse to suspect that a child with meningitis has developed DIC a. cyanosis noted in hands and feet b. dyspnea on exertion c. hemorrhagic skin rash d. facial edema

c. hemorrhagic skin rash

which action should the nurse take first when admitting a multigravid client at 36 weeks gestation with a probable diagnosis of abruptio placentae? a. prepare the client for a vaginal examination b. obtain a brief health history from the client c. insert a large-gauge intravenous catheter d. prepare the client for an ultrasound scan

c. insert a large-gauge intravenous catheter

approximately 90 minutes after birth the nurse notes that the client's fundus is boggy and located about the umbillicus. What is the nurses priority intervention? a. insert a straight catheter to empty the bladder b. asses the amount of lochia on the clients pad c. massage the clients fundus d. notify the healthcare provider

c. massage the clients fundus

during labor, a primigravid client receives and epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. which finding suggests an adverse reaction to the anesthesia. a. fetal tachycardia b. maternal tachycardia c. maternal hypotension d. maternal oliguria

c. maternal hypotension

the parent of an 11- year old male, and 10-year old female has concerns about Gardasil vaccine and asks about the benefits to receiving the vaccine. The nurse should instruct the parent the Gardasil vaccine offer protection against the cancers listed below except: a. cervical b. ovarian c. oropharyngeal d. penile

c. oropharyngeal

a 65- year old male with erectile dysfunction as the nurse, "is all this just in my head?" Am I crazy?" What should the nurse tell the patient? a. " do you have nocturnal erections? if you do, then you have a physiological problems." b. you are right. erectile dysfunction is primarily a psychogenic problem." c. "erectile dysfunction is an uncommon problem among me older than 65." d. "over 50% of erectile dysfunction cases can be attributed to physiologic causes."

d. "over 50% of erectile dysfunction cases can be attributed to physiologic causes."

A mother expressed concern because her three-year old son is fondling his penis. The mother does not know the best approach for the child's behavior. What is the nurse's best response to the mother? a. "this is a strong sign that the is ready for toilet training." b. "you should just discourage this behavior now because it worsens as he gets older." c. "we should obtain a urine sample to assess for infection." d. "this is a normal behavior of his age."

d. "this is a normal behavior of his age."

The nurse has obtained a urine specimen from a multiparous patient admitted to the labor unit. the woman asks to go the bathroom and reports that she feels she has to move her bowels. which action would be most appropriate? a. assist her the bathroom b. ask is she had back pain with previous births c. apply an external fetal monitor to obtain fetal heart rate d. assess her stage of labor

d. assess her stage of labor

The nurse is caring for 3 year old client who has polycythemia. what is the most important intervention for the nurse to include in this child's plan of care to prevent excessive clotting? a. administration of analgesics b. sodium-restricted diet c. use of a soft toothbrush d. encouragement of fluid intake

d. encouragement of fluid intake

while instructing the patient about breast feeding, which one of the following instructions should the nurse include to help the mother prevent matistis? a. change breast pads in bra daily b. wash your nipples with soap and water c. make sure the baby grasps only the nipple d. expose your nipples to air part of the part

d. expose your nipples to air part of the part

a patient with a 28 day menstrual cycle reports that she ovulated on May 10. the nurse would expect the patient's next menses to begin on: a. june 2st b. may 30th c. may 26th d. may 24th

d. may 24th

HELLP syndrome is most closely associated with which pregnancy complication? a. Rh incompatibility b. gestational diabetes c. preterm labor d. pre-elcampsia

d. pre-elcampsia

a client with DVT has been receiving warfarin for 2 months. the client is to go to an anticoagulant monitoring lab every 3 week. the last visit to the lab was 2 weeks ago. the client reports bleeding gums, increased bruising, and dark stools. what should the nurse instruct the client to do? a. decrease the dose of warfarin b. decrease the amount of vit k in the diet c. return to lab for PTT d. return to lab for PT

d. return to lab for PT

a client who sustained a pulmonary contusion in a motor vehicle crash developes a PE. which assessment findings take priority with this client? a. cap refil = 3 sec b. heart rate 115 c. acute pain related to tissue trauma d. shortness of breath

d. shortness of breath

a patient's family member has been told the patient has DIC, but they have no idea what it is. how would the nurse best explain what is happening in DIC? a. the hemolytic process begins to destroy erythrocytes in DIC b. the patients immune system is destroying their own platelets c. DIC is a complication of chemotherapy d. there is an abnormal activation of clotting in DIC

d. there is an abnormal activation of clotting in DIC