Practice Questions
A nurse is preparing to care for a client experiencing dystocia. To which of the following interventions does the nurse give priority? a) Monitoring fetal status b) Providing comfort measures c) Changing the client's position d) Informing the client's partner of the progress of the labor
a) Monitoring fetal status
The nurse is caring for a 10-year-old child with hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurse take when interacting with the child and mother? a) No special precautions are needed b) Wear gloves only c) Wear gloves and a mask d) Wear a mask, gloves and gown
a) No special precautions are needed
Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note? a) Abdomen soft to palpation b) Uterine tender to palpation c) Uterine contractions every 3 to 5 minutes d) Lack of uterine irritability or tetanic contractions
b) Uterine tender to palpation
The nurse is working at a family planning clinic. Under which circumstance should a client who is taking oral contraceptives for birth control be told to use additional protection? a) During the first three months postpartum. b) When taking antibiotics for an infection. c) If she has an elevated serum cholesterol. d) For six months while breastfeeding.
b) When taking antibiotics for an infection.
A pancreatic enzyme preparation is prescribed for a child with cystic fibrosis (CF). The licensed practical nurse (LPN) reinforces instructions to the child's mother to administer the pancreatic enzyme: a) At noon only b) With meals and snacks c) 2 hours after breakfast and dinner d) At bedtime and in the morning when the child awakens
b) With meals and snacks
A 60-year-old client with cancer of the liver is in a hepatic coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one? a) The clients condition is extremely critical. Has your family made funeral arrangements?" b) Your loved one's condition is very critical, and there has been no response in the last 24 hours." c) The nurses have not been able to arouse the client and the healthcare provider knows the outcome." d) You need to discuss the condition with the charge nurse in a family conference."
b) Your loved one's condition is very critical, and there has been no response in the last 24 hours."
The practical nurse (PN) is preparing to insert an older client's bilateral hearing aids. After determining which mold is right and left ear and checking the batteries to be sure they are working properly, in what order should the PN implement? 1Turn the hearing aid off and set the volume at low. 2Line up the ear mold with the client's external auditory opening. 3Rotate the ear mold slightly forward and insert in the ear canal. 4Gently press ear mold into ear while rotating backwards. 5Turn the hearing aid on and adjust the volume for the client.
1Turn the hearing aid off and set the volume at low. 2Line up the ear mold with the client's external auditory opening. 3Rotate the ear mold slightly forward and insert in the ear canal. 4Gently press ear mold into ear while rotating backwards. 5Turn the hearing aid on and adjust the volume for the client.
The healthcare provider gives a pregnant woman a prescription for one prenatal vitamin with iron daily, and tells her that she needs to increase iron rich foods in her diet because her hemoglobin is 8.2 grams/dl. When a list of iron rich foods is given to the client, she tells the practical nurse (PN) that she is vegetarian and does not eat anything that "bleeds." Which instructions should the PN provide? (Select all that apply.) a) Eat red meat just until the anemia is resolved. b) Increase green leafy vegetables in the diet. c) Take two prenatal vitamins with iron daily. d) Oatmeal is a good choice for breakfast. e) Add lentils and black beans to soups.
BDE
A pregnant client is seen in the clinic for the first time. This is the client's first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? Select all that apply. a) "I need to follow the prescribed diabetic diet." b) "I need to limit my exercise while I'm pregnant." c) "I need to report signs of infection to my physician." d) "My insulin requirements may change while I'm pregnant." e) "I'll come back for a prenatal visit every month during my first trimester."
BE
A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply. a) A primipara b) A 36- year-old c) A hypertensive client d) A pack-a-day smoker e) A client who exercises regularly
CD
The home health nurse observes an elderly male client attempt to open a child-proof medication container. When he is unsuccessful in opening the container, he throws it across the room and curses loudly. What action should the nurse implement? a) Transfer the medications to another bottle that is easier to open b) Leave the client;s home immediately and plan to return later c) Ignore the outburst and demonstrate how to open the bottle d) Describe other types of medication containers that are available
Describe other types of medication containers that are available
An elderly male resident in an extended care facility has been told that he must increase his intake of fluids. Which nursing action would be most helpful to this resident? a) Offer a glass of fluid q1h while the client is awake. b) Maintain a full pitcher of water at the bedside. c) Determine what soft drinks the client prefers. d) Demonstrate to the client that his skin turgor is poor.
a) Offer a glass of fluid q1h while the client is awake.
What instruction should the nurse give to a client with fibrocystic breast disease? a) "Eliminate caffeine from your diet" b) "Wear a tight-fitting bra. " c) "Eat a low-carbohydrate, high-protein diet." d) "Increase high-calcium foods in your diet."
a) "Eliminate caffeine from your diet"
A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures? a) "I need to drink at least 2000 mL of fluid a day." b) "I should cut back on my fluid intake in the evening." c) "I need to avoid emptying my bladder so frequently." d) "I should avoid drinking large amounts of fluids during the day."
a) "I need to drink at least 2000 mL of fluid a day."
An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He shares this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? a) Use an over the counter stool softener when needed b) Eat a high protein diet c) Increase the fluid intake in your diet d) Decrease the fat content in your diet
c) Increase the fluid intake in your diet
A licensed practical nurse (LPN) is reinforcing home care instructions to the mother of a child who has undergone cleft lip repair. Which statements by the mother indicate an understanding of these instructions? Select all that apply. a) "I should put her on her stomach to sleep." b) "I shouldn't brush her teeth for 1 to 2 weeks." c) "I should rinse her mouth with water after feeding her." d) "I should watch signs of infection like drainage or fever." e) "I should never use a bulb syringe to clear secretions from her mouth."
a) "I should put her on her stomach to sleep." b) "I shouldn't brush her teeth for 1 to 2 weeks." c) "I should rinse her mouth with water after feeding her."
The practical nurse (PN) is obtaining fetal heart rates on four antepartum clients in their third of pregnancy. Which fetal heart rate should be reported to the registered nurse (RN) immediately? a) 180. b) 152. c) 136. d) 118.
a) 180.
The nurse is administering the shingles vaccine to an older male client who asks why he should receive the immunization. Which information should the nurse provide? a) A history of chickenpox indicates that he harbors the dormant virus b) The client;s last dose of adult immunizations was 10 years ago c) A recent outbreak of fever blisters indicates reactivation of the virus d) Multiple stressful personal experiences increase his risk of shingles
a) A history of chickenpox indicates that he harbors the dormant virus
The nurse is working on a cancer detection mobile clinic. Four individuals come for screening with a complaint of hoarseness, which is a danger sign for cancer of the larynx. Which client has the greatest risk of having cancer of the larynx? a) An auctioneer who chews tobacco and drinks a six pack of beer every night. b) An opera singer who does not smoke but drinks a glass of wine each day. c) An elementary school teacher whose spouse smokes cigars. d) A farmer who smokes a half pack of cigarettes daily.
a) An auctioneer who chews tobacco and drinks a six pack of beer every night.
The licensed practical nurse (LPN) is reinforcing information to the mother of a child with newly diagnosed celiac disease. What piece of information should the nurse include? a) An infection can precipitate a celiac crisis. b) The disease can be cured with medication. c) Pasta is an appropriate part of the child's diet. d) Temporary dietary modifications may be necessary to heal the gastrointestinal tract.
a) An infection can precipitate a celiac crisis.
The nurse is receiving a client following an emergency Cesarean Section (C- Section). Which information is most important for the nurse to obtain? a) Blood pressure and pulse rate b) Gravida and parity c) Medications received during labor d) Temperature and respiratory rate
a) Blood pressure and pulse rate
The licensed practical nurse is reinforcing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child: a) Boiled rice b) Cooked wheat paste c) Warm oatmeal d) Baked wheat macaroni and cheese
a) Boiled rice
What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day? a) Cleanse the radiated area with water and pat the skin dry b) Lightly massage the radiated skin with a lanolin-based lotion c) Rinse the site with normal saline and cover with a sterile towel d) Use a soft washcloth to gently remove the skin marking
a) Cleanse the radiated area with water and pat the skin dry
The nurse is administering multiple medications to a 78-year- old client because of problems related to polypharmacy. At this client's age, which assessment is most important for the nurse to make? a) Cumulative serum drug levels and toxicity b) Synergistic actions due to simultaneous administration c) Tolerance to drugs that has been taken for long periods of time d) Antagonist actions of multiple medications
a) Cumulative serum drug levels and toxicity
The nurse is administering routine medications to an assigned group of elderly clients at an extended care facility. Which physiological change commonly associated with aging increase the elderly client's risk of having adverse response to the medication? a) Decreased gastrointestinal motility b) Poor cognitive function c) Poor peripheral circulation d) Decreased mobility
a) Decreased gastrointestinal motility
A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply. a) Drooling b) Wheezing c) Hiccuping d) Short periods of apnea e) Excessive oral secretions f) Bowel sounds over the chest
a) Drooling e) Excessive oral secretions
The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus? a) Encourage the client to eat foods high in protein b) Assess the client with daily range of motion exercises c) Teach the family how to perform sterile wound care d) Ensure the IV fluids are administered as prescribed
a) Encourage the client to eat foods high in protein
The practical nurse (PN) is caring for a 3-month-old male infant two days after a pyloromyotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement? a) Give prescribed analgesic. b) Obtain blood glucose level. c) Wrap him with a warm blanket. d) Burp the infant every 2 hours.
a) Give prescribed analgesic.
The nurse is caring for a group of clients on a postpartum unit. After shift report, which client should the nurse assess first? a) Gravida 3 Para 3 who delivered vaginally 2 hours ago. b) Gravida 1 Para 2 who is preparing for discharge. c) Gravida 1 Para 0 who is not having contractions. d) Gravida 6 Para 4 who delivered vaginally 24 hours ago.
a) Gravida 3 Para 3 who delivered vaginally 2 hours ago.
he mother of a child with hemophilia calls the clinic nurse and reports that her child has hit his knee on the corner of a coffee table and that the joint appears swollen. The nurse should tell the mother immediately to: a) Immobilize the affected joint b) Take the child to the emergency department c) Elevate the affected joint and apply a heating pad d) Bring the child to his primary healthcare provider
a) Immobilize the affected joint
A child is diagnosed with tracheoesophageal fistula (TEF). Which nursing intervention is the priority for this child? a) Keep suction equipment available at all times. b) Prepare the child for a barium swallow. c) Feed small frequent meals. d) Give isotonic enemas as prescribed.
a) Keep suction equipment available at all times.
A newborn infant with a tracheoesophageal repair is receiving gastrostomy (GT) feedings postoperatively. What intervention should the nurse implement during the GT feedings? a) Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings b) Flush the GT with 50mL of water and clamp the GT to prevent leakage c) Place the infant in the right lateral position to facilitate gastric emptying d) Burp the infant after each 10mL of formula administration and re-feed any volume that is spit up
a) Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings
A licensed practical nurse (LPN) is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should tell the mother to: a) Pad crib rails and table corners b) Use baby aspirin for pain relief c) Use a soft toothbrush for dental hygiene d) Use a generous amount of lubricant when taking the child's temperature rectally
a) Pad crib rails and table corners
36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first? a) Palpate the bladder for distension b) Ask the client when her last bowel movement occurred c) Catheterize the client and record the amount d) Assess the amount of lochia
a) Palpate the bladder for distension
A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician's office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: a) Positions the client on her side b) Calls the physician to see the client c) Places a cool washcloth on the client's forehead d) Checks the client's blood pressure, pulse, and respirations
a) Positions the client on her side
The nurse should recommend that males over the age of 45 obtain which test to screen for prostatic cancer? a) Prostate-specific antigen (PSA) b) Alpha-fetoprotein radio immunoassay (AFP) c) Ultrasound of the scrotum d) Serum testosterone level
a) Prostate-specific antigen (PSA)
A client tells the nurse that he is afraid about his scheduled surgery. How should the nurse respond? a) Tell me what is making you feel afraid." b) It is normal to have some fears before surgery." c) Would you like to speak with the surgeon?" d) I was afraid before I had surgery, too."
a) Tell me what is making you feel afraid."
An elderly female client tells the nurse that she does not do regular breast self-examination (BSE) because she is too old. The nurses response to the client is based on what information? a) The incidence of breast cancer increases with age b) The client should have a health care provider do a breast exam at least once a year c) After age 70, breast cancer is less likely to occur
a) The incidence of breast cancer increases with age
The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse? a)The mother's version of the injury is different from the child's version. b) The child looks at the floor when answering the nurse;s questions. c) The mother refuses to answer questions about family history. d) The child has several abrasions on the chest and legs. Maternal and Newborn
a)The mother's version of the injury is different from the child's version.
A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first: a) Notifies the registered nurse b) Documents the findings c) Instructs the client to take several deep breaths d) Administers 100% oxygen by way of face mask
c) Instructs the client to take several deep breaths
A 3-week-old infant is admitted for surgical repair of pyloric stenosis. What intervention should the nurse expect to implement to establish hydration in the immediate postoperative period? a) Diaper weights and urine specific gravity b) Gastronomy feedings in supine position c) Nipple feedings with glucose water d) Gavage feedings with 15 mL of formula
c) Nipple feedings with glucose water
During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, "I don't eat regular meals." The appropriate response is: a) "Weight loss could hurt your baby." b) "Let's make a list of what you're eating." c) "I'll have the doctor review your diet history." d) "It's all right to gain weight during pregnancy."
b) "Let's make a list of what you're eating."
The use of a Pavlik harness has been prescribed for an infant with developmental dysplasia of the hip, and the nurse reinforces instructions to the mother about the use of the harness. Which statement by the mother indicates the need for further instruction? a) "The diaper is put on under the harness." b) "The harness is placed against the skin to provide support." c) "I need to support her hips and buttocks when the harness is off." d) "The harness straps should be secure enough to keep her hips flexed but not tight."
b) "The harness is placed against the skin to provide support."
A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that: a) A rubella vaccine must be administered immediately b) A rubella vaccine must be administered after childbirth c) She will not contract rubella if she is exposed to the disease d) She does not need to be concerned about being exposed to rubella
b) A rubella vaccine must be administered after childbirth
A child with a history of sickle cell disease is seen in the emergency department, where acute sequestration crisis is diagnosed. The nurse should immediately prepare to: a) Administer pain medication b) Assist with starting an intravenous (IV) line c) Obtain informed consent for a splenectomy d) Place a cold pack on the abdomen over the area of the spleen
b) Assist with starting an intravenous (IV) line
A nurse is caring for an infant with Hirschsprung's disease. Which manifestation of the disease should the nurse expect to see? a) Non-bilious projectile vomiting b) Foul-smelling, ribbon-like stools c) A sausage-shaped abdominal mass d) Bloody, mucousy "currant jelly" stools
b) Foul-smelling, ribbon-like stools
Hydrostatic reduction is performed in a hospitalized child with a diagnosis of intussusception. Which outcome indicates that the procedure was successful? a) Passage of barium in the stool b) Passage of stool without blood c) Visible peristalsis across the abdomen d) Presence of a sausage-shaped abdominal mass
b) Passage of stool without blood
A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation? a) Umbilical cord compression b) Pressure on the fetal head during a contraction c) Adequate pacemaker activity of the fetal heart d) Uteroplacental insufficiency during a contraction
b) Pressure on the fetal head during a contraction
The licensed practical nurse (LPN) is reinforcing information to the parents of a child with suspected Hirschsprung's disease. The nurse informs the parents that diagnosis is definitively confirmed by the findings of: a) Blood tests b) Rectal biopsy c) Barium enema d) Rectal examination
b) Rectal biopsy
The practical nurse (PN) is preparing a child with an intussusception for a prescribed barium enema. The PN should explain to the parent that the purpose for conducting this procedure prior to surgical intervention is to achieve what objective? a) Evacuate the bowel of impacted feces b) Reduce the invaginated bowel segment c) Locate the presence of diverticula d) Identify the area of esophageal atresia
b) Reduce the invaginated bowel segment
The nurse is caring for a primigravida 5 hours after a vaginal delivery. Which finding should the nurse report immediately to the charge nurse? a) Pulse rate of 90 beats/minute b) Rubra lochia saturating 3 perineal pads per hour c) Complaints of perineal pain d) Firm fundus between umbilicus and the symphysis pubis
b) Rubra lochia saturating 3 perineal pads per hour
The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, What do these letters T1N0M0 stand for?; Which response should the nurse provide first? a) The letters are used to predict the prognosis of the cancer or tumor." b) The letters stand for tumor size, node involvement and metastasis." c) Let me refer you to the charge nurse." d) Are you confused? Would you like to talk?
b) The letters stand for tumor size, node involvement and metastasis."
An infant with developmental hip dysplasia is placed in a Pavlik harness, and the nurse reinforces the information given the mother on how to care for her infant. In evaluating the mother's learning, which information indicates that the mother understands proper care for her child? a) The harness straps should be adjusted to increase leg movement. b) The skin should be checked frequently for reddened areas. c) The harness straps should be placed next to the skin. d) The harness can be removed intermittently during the day.
b) The skin should be checked frequently for reddened areas.
A nurse caring for a hospitalized client with a diagnosis of abruptio placentae and develops a nursing care plan incorporating intervention to be implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately: a) Limit maternal activity b) Turn the client on her side c) Monitor maternal vital signs d) Provide emotional support to reduce anxiety
b) Turn the client on her side
A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is: a) "Yes, the newborn will also have the virus." b) "HIV can only be transmitted through sexual contact." c) "The newborn does have a risk of contracting the infection." d) "The newborn will have signs of HIV at birth if the virus has been transmitted."
c) "The newborn does have a risk of contracting the infection."
A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as: a) 8 to 10 weeks of gestation b) 11 to 13 weeks of gestation c) 14 to 16 weeks of gestation d) 18 to 20 weeks of gestation
c) 14 to 16 weeks of gestation
A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. In light of this finding, which nursing action is the priority? a) Documenting the finding b) Preparing for immediate birth c) Administering oxygen by way of face mask d) Increasing the rate of the oxytocin (Pitocin) infusion
c) Administering oxygen by way of face mask
A nurse is assisting a physician in performing a physical examination of a client who has just been told that she is pregnant. The physician tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: a) The presence of fetal movement b) A high risk for spontaneous abortion c) An increase in vascularity and hypertrophy of the cervix d) The presence of human chorionic gonadotropin (hCG) in the urine
c) An increase in vascularity and hypertrophy of the cervix
A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: a) Indicate that labor has started b) Must be reported to the physician c) Are a common occurrence of pregnancy d) Necessitate bed rest for the remainder of the pregnancy
c) Are a common occurrence of pregnancy
The nurse is discussing birth control methods with a new mother. The client says that she will not need any birth control because she will not have a menstrual period if she is breastfeeding. What information should the nurse provide? a) Breastfeeding will usually inhibit menstruation, so pregnancy will not occur until menses begins. b) This is a safe and natural choice. Birth control practices can be started when the baby is weaned. c) Breastfeeding is not a reliable form of birth control because ovulation can occur before menses returns. d) Birth control pills may be needed to regulate hormone until menses returns to normal.
c) Breastfeeding is not a reliable form of birth control because ovulation can occur before menses returns.
A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: a) Vitamin K b) Protamine sulfate c) Calcium gluconate d) Naloxone hydrochloride
c) Calcium gluconate
The first day after a cesarean section (C-Section), when being assisted to the bathroom for the first time, a primavera client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take? a) Insert an indwelling catheter to empty the bladder and contract the fundus b) Return the client to bed and maintain bed rest until the lochial flow slows c) Check fundal consistency and continue to monitor the lochial flow amount d) Massage the fundus and avoid direct pressure on the cesarean incision
c) Check fundal consistency and continue to monitor the lochial flow amount
A licensed practical nurse (LPN) is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the LPN to contact the registered nurse? a) Complaint of feeling hot b) Enlargement of the breasts c) Diaphoresis and tachycardia d) Periods of fetal movement followed by quiet periods
c) Diaphoresis and tachycardia
A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: a) Eat foods high in calories and fat b) Lie down for at least 20 minutes after meals c) Eat carbohydrates such as cereals, rice, and pasta d) Consume primarily soups and liquids at mealtimes
c) Eat carbohydrates such as cereals, rice, and pasta
A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat? a) Fetoscope b) Adult stethoscope c) Electronic Doppler d) Fetal heart monitor
c) Electronic Doppler
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to: a) Notify the registered nurse b) Recheck the temperature in 1 hour c) Encourage the intake of oral fluids d) Tell the client that antibiotics will be prescribed
c) Encourage the intake of oral fluids
A 67-year-old woman who lives alone tripped on a rug in her home and fractured her right hip. The nurse knows that which predisposing factor contributes to the occurrence of hip fractures among elderly women? a) Urinary retention resulting in renal calculi formation b) Failing eyesight resulting in an unsafe environment c) Osteoporosis resulting from hormonal changes d) Transient ischemic attacks (TIAs) which impair mental acuity
c) Osteoporosis resulting from hormonal changes
A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: a) Walk half a mile 3 times a week b) Drink at least 2 quarts of fluid per day c) Perform Kegel exercises in 10 repetitions, three times per day d) Perform pelvic tilt exercises in 10 repetitions, three times per day
c) Perform Kegel exercises in 10 repetitions, three times per day
A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement? a) Assessing the cervix for thinning b) Auscultating for fetal heart sounds c) Performing a sudden tap on the cervix d) Palpating the abdomen for fetal movement
c) Performing a sudden tap on the cervix
A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is: a) Preparing to induce labor b) Turning the client on her left side c) Preparing the client for a cesarean delivery d) Continuing to monitor the fetal heart rate pattern
c) Preparing the client for a cesarean delivery
A licensed practical nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the LPN to contact the registered nurse? a) Urine output of 20 mL b) Deep tendon reflexes of 2+ c) Respirations of 10 breaths/min d) Fetal heart tone of 116 beats/min
c) Respirations of 10 breaths/min
A client is having radical mastectomy. What is the position of choice during the immediate postoperative period? a) Side-lying on the operative side with the bed flat b) Supine with the arm on the operative side in a dependent position c) Semi-Fowler's position with the arm on the operative side elevated d) Sim's position with the arm on the operative side in a dependent position
c) Semi-Fowler's position with the arm on the operative side elevated
nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: a) Has the client void before the uterine assessment 2 b) Tells the woman to bear down during fundal message c) Simultaneously provides pressure over the lower uterine segment d) Asks the client to take slow, deep breaths during fundal assessment
c) Simultaneously provides pressure over the lower uterine segment
A 12-year-old with type 1 diabetes mellitus complains of abdominal pain and has experienced increased thirst for the past 24 hours. What action should the practical nurse implement first? a) Obtain blood for a serum glucose b) Initiate D10W at 50 ml/hour IV c) Test urine for ketones and glucose d) Assess temperature and blood pressure
c) Test urine for ketones and glucose
The mother of an adolescent with type 1 diabetes mellitus tells the licensed practical nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. After reinforcing teaching regarding diet, exercise, insulin, and blood glucose, provided earlier by the registered nurse, the licensed practical nurse tells the mother: a) To always administer less insulin on the days of soccer games b) That it is best not to encourage the child to participate in sports activities c) That the child should eat a carbohydrate snack about a half- hour before each soccer game d) To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL or higher and ketones are present
c) That the child should eat a carbohydrate snack about a half- hour before each soccer game
An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client? a) The physical therapist will instruct the client in the use of a walker b) The nurse will place a gait belt on the client prior to ambulation c) The client will ambulate with assistance q4h d) The client will use self-affirmation statements to decrease fear
c) The client will ambulate with assistance q4h
A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears? a) "Urinary infections during pregnancy are common. Your baby will be fine." b) "Your developing baby cannot acquire an infection from you during pregnancy." c) "You shouldnt worry about this, because you had early prenatal care and are taking your prenatal vitamins." d) "Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today."
d) "Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today."
A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL. The nurse tells the client that: a) Daily NPH insulin will be needed b) Her glucose level is within normal limits c) A daily oral hypoglycemic agent will be prescribed d) A 3-hour glucose tolerance test will likely be performed to confirm gestational diabetes
d) A 3-hour glucose tolerance test will likely be performed to confirm gestational diabetes
A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: a) Lie down b) Contact the physician c) Drink 8 oz of diet soda d) Check her blood glucose level
d) Check her blood glucose level
A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client? a) A lack of cervical changes b) A soft uterus with indentable contractions c) Contractions that are irregular in rhythm and duration d) Contractions that begin in the lower abdomen and back and radiate over the entire abdomen
d) Contractions that begin in the lower abdomen and back and radiate over the entire abdomen
The practical nurse (PN) is caring for a child who has had a cleft lip repair. What is the most important reason to minimize the child's crying during the postoperative recovery period? a) Tear formation increases salivation b) This behavior increases respirations c) Lack of comforting can enhance pain d) Crying stresses the suture line
d) Crying stresses the suture line
The nurse is preparing a client for a mammogram. What instruction should the nurse provide the client? a) Do not exercise the upper body on the day of the procedure. b) Avoid taking aspirin for one week prior to the procedure. c) Avoid eating or drinking 6 hours prior to the procedure. d) Do not use underarm deodorant on the day of the procedure.
d) Do not use underarm deodorant on the day of the procedure.
A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort? a) Drink fluids with meals b) Eliminate the morning meal c) Eat fatty or spicy foods only at the noontime meal d) Eat dry crackers every 2 hours to prevent an empty stomach
d) Eat dry crackers every 2 hours to prevent an empty stomach
The care plan for a male client with amyotrophic lateral sclerosis includes the Nursing diagnosis, "Decisional conflict related to concerns about mechanical ventilation." When assigned to care for this client, what intervention should the nurse implement based on this diagnosis? a) Provide an opportunity for the client to meet with survivors of the disease who have undergone mechanical ventilation b) Remind the client that a mechanical ventilator is usually only needed for a short period of time c) Ask the hospice nurse to visit with the client to discuss his options for care if he chooses not to undergo mechanical ventilation d) Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation
d) Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation
A male client who was admitted with gangrene of the right lower extremity is confused, and his wife refuses to sign the operative permit for an above-the- knee amputation. What action should the practical nurse (PN) take next? a) Document on the client record the refusal for surgical treatment. b) Notify the RN that the client's wife needs further explanation about the procedure. c) Explain the consequences of sepsis if the amputation is delayed. d) Encourage the client's wife to express concerns about making the decision.
d) Encourage the client's wife to express concerns about making the decision.
A client in the third trimester of pregnancy reports that she feels some;lumpy places; in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? a) Recommend that the client wear a supportive brassiere to prevent leaking of fluid. b) Reschedule the client;s prenatal appointment for the following day. c) Obtain additional data by asking the client if her areolae have become darker. d) Explain that this is normal, but can be assessed further at the next prenatal visit.
d) Explain that this is normal, but can be assessed further at the next prenatal visit.
A client asks the nurse about breast cancer risk factors. Which factor should the nurse emphasize as high risk? a) Multiparity, late menarche, early menopause. b) Short term or no history of birth control pill usage. c) Age 28 years and removal of benign fibrocystic lump. d) First degree relative with a history of breast cancer.
d) First degree relative with a history of breast cancer.
Laboratory studies are performed on a client with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease? a) Low reticulocyte count b) Low total bilirubin level c) Increased hematocrit count d) Increased white blood cell (WBC) count
d) Increased white blood cell (WBC) count
A client who has four gold seed implants on a chest wall tumor is on radiation precautions. What basic precautions should the nurse observe when administering direct care to this client? a) Standard precautions with negative pressure isolation. b) Virtual observation and wear a film bandage for exposure. c) Rotate the assignment with other staff during the shift. d) Minimal time, maximum distance, and protective shielding.
d) Minimal time, maximum distance, and protective shielding.
The practical nurse (PN) is caring for an infant with pyloric stenosis. What nursing intervention should be included in the preoperative period? a) Monitor for signs of metabolic acidosis b) Estimate the quantity of diarrhea stools c) Place in a supine position after feeding d) Observe for projectile vomiting
d) Observe for projectile vomiting
What manifestation of hypertrophic pyloric stenosis should the nurse reviewing the record of an infant with this disorder expect to see documented? a) Fever b) Profuse diarrhea c) Alternating constipation and diarrhea and fecal impaction d) Olive-shaped mass palpated in the right upper abdominal quadrant
d) Olive-shaped mass palpated in the right upper abdominal quadrant
A client tells the practical nurse (PN) that she has a family history of cancer and has increased the amount of dairy products in diet reduce her risk of getting cancer. How should the PN respond? a) Suggest that an increase in fruits and vegetables would be more beneficial. b) Remind the client to make sure the dairy products are fortified with Vitamin D. c) Encourage the client to get plenty of exercise as well as the dietary change. d) Provide written information about the seven warning signs of cancer.
d) Provide written information about the seven warning signs of cancer.
During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the nurse take? a) Withhold any medications that may cause these side effects b) Motivate the client by offering favorite foods as a prize c) Ask the family members to visit more often to stimulate the client d) Record the findings and report the symptoms to the charge nurse
d) Record the findings and report the symptoms to the charge nurse
An older male client tells the nurse that his religion does not a bath today: a) dont bathe him b) ??? c) Offer the client several choices of time to bathe during the day d) Request that the client clarify his religious beliefs about bathing
d) Request that the client clarify his religious beliefs about bathing
A newborn is found to have esophageal atresia (EA) with tracheoesophageal fistula (TEF). In which position does the nurse immediately place the infant? a) Trendelenburg b) Flat and side-lying c) Prone, with the head of the bed flat d) Supine, with the head of the bed elevated
d) Supine, with the head of the bed elevated
A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client: a) To perform a vaginal douche b) To come to the clinic for a checkup c) That this is an indication of an infection d) That this is a normal postpartum occurrence
d) That this is a normal postpartum occurrence
A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? a) Clonus is present. b) Magnesium level is 10 mg/dL. c) Deep tendon reflexes are absent. d) The client experiences diuresis within 24 to 48 hours.
d) The client experiences diuresis within 24 to 48 hours.
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that: a) She must be retested in 1 week b) Liver function tests will be prescribed c) A repeat hepatitis screen will be performed during the pregnancy d) The infant should receive both the vaccine and hepatitis immune globulin soon after birth
d) The infant should receive both the vaccine and hepatitis immune globulin soon after birth
A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: a) The infant must be isolated from the mother after birth b) Maternal medication will not be started until the baby is born c) The infant will require medication therapy immediately after birth d) The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months
d) The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months