Quiz 1-Synthesis

The nurse is conducting a counseling session with a client experiencing PTSD using a 2-way video telehealth system from the hospital to the client's home, which is 2 hours away from the nearest mental health facility. Which of the following are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will: 1. Save travel time from the house to the health care facility 2. Avoid reliving a traumatic event that might be precipitated by visiting a health care facility 3. Experience a shorter recovery time than being treated on-site 4. Receive health care for this mental health problem 5. Obtain group support from others with a similar health problem

1, 2, 4

During the process of restraining a client, a staff member is injured. The nurse manager would conclude that a peer support program has been helpful for the injured staff member if which of the following outcomes had been achieved? Select all that apply 1. The injured staff member has debriefed with the other staff involved in the restraint 2. Legal action has been taken against the client 3. The injured staff member had the opportunity to express his or her feelings with a support group. 4. The injured staff member has decided whether or not to talk to the assaultive client. 5. A plan has been arranged to facilitate the return of the injured staff member to work.

1, 3, 4, 5

A 26 year old G1P1 patient who underwent cs 24 hours ago tells the nurse that she is having some trouble breast-feeding. Which tasks could be appropriately delegated to the UAP on the postpartum floor? Select all that apply 1. Providing the mother with an ordered abdominal binder 2. Assisting the mother with breast-feeding 3. Taking the mothers VS 4. Checking the amount of lochia present 5. Assisting the mother with ambulation

1, 3, 5

A client is receiving digoxin and the pulse range is normally 70-76 bpm. After assessing the apical range for 1 minute and finding it to be 60 bpm, the nurse should first: 1. Notify the physician 2. Withhold the digoxin 3. Administer the digoxin 4. Notify the charge nurse

2

A female client is admitted with fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The nurse should conduct a focused assessment for further signs of: 1. Cushings disease 2. Hypothyroidism 3. Hyperthyroidism 4. A pituitary tumor

2

The nurse assesses a client with diverticulitis. The nurse should report which of the following to the HCP? 1. Hyperactive bowel sounds 2. Rigid abdominal wall 3. Explosive diarrhea 4. Excessive flatulence

2

The nurse is preparing a teaching plan for a 45 year old client recently diagnosed with type 2 DM. What is the first step in this process? 1. Establish goals 2. Choose video materials and brochures 3. Assess the client's learning needs 4. Set priorities

3

The nurse holds the gauze pledget against an IM injection site while removing the needle from the muscle. This technique helps to 1. Seal off the track left by the needle in the tissue 2. Speed the spread of the medication in the tissue 3. Avoid the discomfort of the needle pulling on the skin 4. Prevent organisms from entering the body through the skin puncture

3. Holding the gauze pledget against an IM injection site while removing the needle from the muscle avoids the discomfort of the needle pulling on the skin.

A client whose condition remains stable after a MI gradually increases activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client? 1. Edema 2. Cyanosis 3. Dyspnea 4. Weight loss

3. Physical activity is gradually increased after a MI while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat or fatigue. When any of these symptoms appear, the client should reduce activity and progress more slowly.

A 67 year old client with BPH has a new prescription for tamulosin (Flomax). Which statement about tamulosin is most important to include when teaching this client? 1. This medication will improve your symptoms by shrinking the prostate 2. The force of your urinary stream will probably increase 3. Your BP will decrease as a result of taking this medication 4. You should avoid sitting up or standing up too quickly

4

The nurse is assessing a client who has had a MI. The nurse notes the cardiac rhythm is shown below. The nurse notes that this rhythm is

4

Which of the following statements indicates that the client with a peptic ulcer understands the dietary modification to follow at home? 1. I should eat a bland, soft diet 2, It is important to eat six small meals a day 3. I should drink several glasses of milk a day 4, I should avoid alcohol and caffeine

4

You are working on the PACU caring for a 32 year old client who has just arrived after undergoing D&C to evaluate infertility. Which assessment finding should be immediately communicated to the surgeon? 1. BP of 162/90 mm Hg 2. Saturation of the perineal pad after the first 30 minutes 3. Oxygen saturation of 91-95% 4. Sharp continuous level 8 (out of 10) abdominal pain

4

Indicate the order in which the RN should take the following actions at this time. 1. Apply a fetal monitor and measure VS 2. Obtain a thorough history from the client 3. Notify the physician 4. Instruct the man to wait in the waiting area and notify security 5. Call a social worker for a consult

4 1 3 2 5

Which response by Ms N would prompt the RN to notify the physician and advise Ms N to go straight to the hospital? 1. The contractions are extremely painful 2. I have vaginal bleeding that soaks about a pad an hour 3. I have vaginal bleeding that is mixed with a lot of mucus 4. My baby is moving a lot today

2

After treatment , Ms N's contractions stop and there is no further cervical dilation. After a day of observation, Ms N is being discharged today. Her discharge meds are prenatal vitamin and ferrous sulfate.

...

Case Study 21: Childbearing

...

A HCP has been exposed to Hep B through a needlestick. WHich of the following drugs should the nurse anticipate administering as postexposure prophylaxis? 1. Hep B immune globulin 2. Interferon 3. Hep B surface antigen 4. Amphotericin B

1

The nurse is caring for a toddler in contact isolation for RSV. In what order should the nurse remove PPE> 1. Gloves 2. Goggles 3. Gown 4. Mask

1 3 2 4

The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a 1. Micron mesh filter 2. Non filtered blood administration set 3. Special leukocyte-poor filter 4. Microdrip administration set

1. All blood products should be administered through a micron mesh filter. Blood is never administered without a filter. Leukocytes can be removed by using leukocyte-poor filters and this is recommended to decrease reaction in clients, such as hemophiliacs, who require frequent transfusions. Blood is too concentrated to administer through a microdrip set.

You are caring for a 21 year old client who had a left orchiectomy for testicular cancer on the previous day. Which nursing activity will you delegate to an LPN? 1. Educating the client about post-orchiectomy chemotherapy and radiation 2. Administering the prescribed PRN oxycodone to the client 3. Teaching the client how to perform testicular self-examination on the remaining testicle. 4. Assessing the client's knowledge level about post-orchiectomy fertility

2

When teaching UAP about the importance of handwashing in preventing disease, the nurse should instruct the UAP that 1. It is not necessary to wash your hands as long as you use gloves 2. Hand washing is the best method for preventing cross-contamination 3. Waterless commercial products are not effective for killing organisms 4. The hands do not serve as a source of infection

2

Which of the following is a priority goal after surgical repair of a cleft lip? 1. Managing pain 2. Preventing infection 3. Increasing mobility 4. Developing parenting skills

2

You are working in the obstetric triage area and several patients have just come in. Which patient should you assess first? 1. A 17 year old G1P0 woman at 40 weeks with contractions every 6 minutes who is crying loudly and is surrounded by anxious family members 2. A 22 year old G3P2 woman at 38 weeks with contractions every 3 minutes who is requesting to go to the bathroom to have a bowel movement 3. A 32 year old G4P3 woman at 27 weeks who noted vaginal bleeding today following intercourse 4. A 27 year old G2P1 woman at 37 weeks gestation who experienced sROM 30 minutes ago but feels no contractions

2

A 68 year old client who is ready for discharge from the ED has a new prescription for nitroglycerin 0.4 mg sl PRN for angina. Which client information has the most immediate implications for teaching? 1. The client has BPH and some urinary hesitancy 2. The client's father and two brothers all have had MIs 3. The client uses Viagra several time weekly for erectile dysfunction 4. The client is unable to remember when he first experienced chest pain

3

A 7 year old child is admitted to the hospital with the diagnosis of acute rheumatic fever. Which of the following laboratory blood findings confirms that the child has had a streptococcal infection? 1. High leukocyte count 2. Low hemoglobin count 3. Elevated antibody concentration 4. Low erhythrocyte sedimentation rate

3

A client has had a needle biopsy of the prostate gland using the transrectal approach. Which statement is most important to include in the client teaching plan? 1. The doctor will call you about the test results in a day or two 2. Serious infections may occur as a complication of this test 3. You will need to call the doctor if you develop a fever or chills 4. It is normal to have a small amount of rectal bleeding after the test

3

A client is trying to lose weight at a moderate pace. If the client eliminates 1000 cal/day from his normal intake, how many pounds would the client lose in 1 week?

2 lb

A client scheduled for hip replacement surgery wish to receive his own blood for the upcoming surgery. The nurse should 1. Document the clients request on the chart 2. Notify the hematology laboratory 3. Notify the surgeons office 4. Call the blood bank

3

The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply. 1. Ask the client to rub lotion over the hands every day after bathing. 2. Encourage physical activity, such as ambulation. 3. Provide frequent contacts for communication and socialization. 4. Provide family education. 5. Encourage involvement of family and friends

2, 3, 4, 5 Socialization and communication, in addition to increased activity, are all means to aid in prevention of self-injury. Education of family members may foster development of strategies to prevent self-injury; hence mitten restraints could be avoided. Applying lotion after bathing may not be appropriate when the skin is broken and not intact.

A 22 year old G1P0 is being given an epidural anesthetic for pain control during labor and birth. Which are appropriate nursing actions when epidural anesthesia is used during labor? Select all that apply 1. Request the anesthesiologist to discontinue the epidural anesthetic when the patient's cervix is completely dilated to allow the patient to sense the urge to push 2. Insert a Foley catheter, because the woman is likely to be unable to void 3. Encourage pushing efforts when the cervix is completely dilated in the absence of an urge to push 4. Encourage the patient to turn from side to side during the course of labor 5. Teach the patient that pain relief can be expected to last 1-2 hours

2, 4

A mother tells the nurse that her 10 year old daughter has an increase in hair growth and breast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty are noticed, menstruation typically occurs within which of the following time frames? 1. 6 months 2. 12 months 3. 30 months 4. 36 months

3

A multigravid client is scheduled for a percutaneous umbilical blood sampling procedure. The nurse instructs the client that this procedure is useful for diagnosing which of the following? 1. Twin pregnancies 2. Fetal lung maturation 3. Rh disease 4. Alpha fetoprotein level

3

The nurse is developing a community health education program about STDs. WHich information about women who acquire gonorrhea should be included? 1. Women are more reluctant than men to seek medical treatment. 2. Gonorrhea is not easily transmitted to women who are menopausal 3. Women with gonorrhea are usually asymptomatic 4. Gonorrhea is usually a mild disease for women

3

The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse should explain that: 1. A disease carrier also has the disease. 2. Two parents who are carriers may produce a child who has the disease 3. A disease carrier and an affected person will never have children with the disease 4. A disease carrier and an affected person will have a child with the disease

2. Cystic fibrosis is the most common inherited disease in children. It is inherited as an autosomal recessive trait, meaning that the child inherits the defective gene from both parents. The chances are one in four for each of the couples pregnancies.

The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate? 1. Cat 2. Fish 3. Gerbil 4. Canary

2. Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold

Using the SBAR format, how will you communicate priority information in report to the ED RN? 1. The client needs evaluation for preterm labor and bleeding. She smokes, has a chlamydia infection, and has had minimal prenatal care. 2. The client is a 20 year old G1P0 with a prepregnancy weight of 130 lb. Current weight is 160 lb. Has a family history of diabetes and twins. Will arrive in the ED within 1 hours because of bleeding and cramping. 3. The client is a 20 year old G1P0 at 24 weeks who reports vaginal bleeding and cramping. She has an elevated 1 hour glucose level, tested positive for chlamydia and was given a med Rx today and had an abnormal Pap test result. She's had only 2 prenatal visits and no ultrasound yet. She is a smoker, reports a lot of stress, is single, unemployed, and with little support. She is coming for evaluation for possible preterm labor and vaginal bleeding. Please be sure she also gets a social work consult and ensure that she has taken the medication for chlamydia. 4. The client is a 20 year old G1P0 coming to the ED with premature labor and placenta previa. She was treated today for chlamydia infection and has been referred for colposcopy for an abnormal Pap test result. Her 1 hour glucose level was elevated. She has had minimal prenatal care and a urine drug screen should be considered.

3

A client with severe depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which of the following? 1. Hallucination 2. Illusion 3. Delusion 4. Paranoia

3. A client with severe depression may experience symptoms of psychosis such as hallucinations and delusions that are typically mood congruent. The statement is a mood congruent somatic delusion. A delusion is a firm, false, fixed belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to suspiciousness of others and their actions.

A client with angina shows the nurse the nitroglycerin that the client carries in a plastic bag in the pocket. The nurse instructs the client that the nitroglycerin should be kept in: 1. The refrigerator 2. A cool, moist place 3. A dark container to shield from light 4. A plastic pill container where it is readily available

3. Nitroglycerin in all dosage forms should be shielded from light to prevent deterioration. The client should be instructed to keep the nitroglycerin in the dark container that is supplied by the pharmacy and it should not be removed or placed in another container.

During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients take an active role in their health care? 1. Ask clients to complete a questionnaire 2. provide clients with written instructions 3. Ask clients for their views of their health and health care. 4. Ask clients if they have any questions about their health.

3. One of the best strategies to help clients feel in control is to ask them their view of situations and to respond to what they say. This technique acknowledges that clients' opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation but alone it does not acknowledge their views.

Under which circumstance may a nurse communicate medical information without the clients consent? 1. When certifying the clients absence from work 2. When requested by the client's family 3. When treating the client with a STD 4. When prescribed by another physician

3. Sexually transmitted disease are communicable disease that must be reported. The nurse is responsible for reporting these disease to the appropriate public health agency and to otherwise maintain the client's confidentiality. The client's family cannot request release of medical information without the client's consent. A physician's prescription is not a substitute for a client's consent to release medical information in the absence of a communicable disease.

Assessment of a client taking lithium reveals dry mouth, nausea, thirst and mild hand tremor. Based on analysis of these findings, which of the following should the nurse do next? 1. Withhold the lithium and obtain a lithium level to determine therapeutic effectiveness 2. Continue the lithium and immediately notify the physician about the assessment findings. 3. Continue the lithium and reassure the client that these temporary side effects will subside. 4. Withhold the lithium and monitor the client for signs and symptoms of increasing toxicity.

3. The client is exhibiting temporary side effects associated with lithium therapy.

When teaching a client with bipolar disorder who has started to take valproic acid (Depakene) about possible side effects of this medication, the nurse should instruct the client to report: 1. Increased urination 2. Slowed thinking 3. Sedation 4. Weight loss

3. Valproic acid causes sedation as well as nausea, vomiting and indigestion. Sedation is important because the client needs to be cautioned about driving or operating machinery that could be dangerous while feeling sedated from the medication. Depakene does not cause increased urination, slowed thinking, or weight loss. However some clients may experience weight gain.

A nurse is relieving the triage nurse in the labor and delivery unit who is going to lunch. The report indicates that there are three clients having their VS assessed and a fourth client is on her way to the unit from the ED. In which order of priority should the nurse manage these clients? 1. the client with clear vesicles and brown vaginal discharge at 16 weeks 2. The client with RLQ pain at 10 weeks 3. The client who is at term and has had no fetal movement for 2 days 4. The client from the ED at term and screaming loudly because of labor contractions

4 2 1 3

A multiparous client tells the nurse that she is using medroxyprogesterone (Depo-Provera) for contraception. The nurse should instruct the client to increase her intake of which of the following? 1. Folic acid 2. Vitamin C 3. Magnesium 4. Calcium

4. The nurse should instruct the client to increase her intake of calcium because there is a slight increase in the risk of osteoporosis with this medication. Weight-bearing exercises are also advised. The drug may also impair glucose tolerance in women who are at risk for diabetes.

At what time should the blood be drawn in relation to the administration of the IV dose of gentamicin sulfate? 1. 2 hours before the administration of the next IV dose 2. 3 hours before the administration of the next IV dose 3. 4 hours before the administration of the next IV dose 4. Just before the administration of the next IV dose

4. To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next IV dose of gentamicin sulfate

When performing an otoscoic examination of the tympanic membrane of a 2 year old child, the nurse should pull the pinna in which of the following directions? 1. Down and back 2. Down and slightly forward 3. Up and back 4. Up and forward

1

Later that evening Ms N calls the clinic and reports vaginal bleeding and cramping. You advise her to go to the ED and tell her that you will notify her provider and the RN in the ED

...

Ms N arrives in the obstetrics triage area crying and accompanied by an agitated man who is speaking angrily to the client

...

Ms N relates that, when she told her partner about the positive chlamydia test result, he became violent and began hitting her in the face and abdomen. Upon exam, Ms N's cervix is found to be 2 cm dilated and 50% effaced, she is contracting every 6 minutes and she has a small amount of vaginal bleeding. Her ultrasound findings are normal and show no placenta previa. She is admitted to the hospital for treatment of preterm labor. The physician has ordered the following meds: Procardia and Betamethasone

...

Ms N's pregnancy continues uneventfully. She separates from her boyfriend and begins counseling, which she says makes her feel stronger and calmer. She has decreased her smoking to 1-2 cigarettes/day. Her mother comes from out of state to live with her and cooks healthy foods. She is now at 38 weeks and calls the RN to report that has had uterine contractions for 6 hours

...

Ms N. returns for her second prenatal appt 1 week later. You review her lab results with her and note the following abnormal findings: 1 hr glucose tolerance test: 190 mg/dl; pap smear results, low grade squamous intraepithelial lesion (LISL) with high risk HPV present; chlamydia test, positive for the organism. The physician has written orders for a 3 hour glucose tolerance test and a colposcopy, and has provided a prescription for azithromycin (Zithromax) 1 g PO. Ms N has increased her smoking to 1 pack/day because of stress

...

Ms. N is a 20 year old G1P0 woman who begins her prenatal care today at 24 weeks gestation. She says that she didn't know she was pregnant until now. Her prepregnancy BMI was 23. She has gained 30 lb so far. She admits that she eats poorly and smokes a half pack of cigarettes daily but claims to use no other substances. She lives with her boyfriend and has no immediate family in the area. She reports no significant medical, surgical or family history. You are the RN taking her history and drawing samples for laboratory work today on this first prenatal visit.

...

A client is prescribed atropine 0.4 mg IM. The atropine vial is labeled 0.5 mg/mL. How many milliliters should the nurse plan to administer? ________________________ mL

0.8 mL

A 16 year old client is in the emergency room for treatment of minor injuries from a car accident. A crisis nurse is with the client because the client became hysterical and was saying, "It's my fault. My mom is going to kill me. I dont even have a way home." Which of the following should be the nurse's initial intervention? 1. Hold her hands and say, "Slow down and take a deep breath" 2. Say, "Calm down. The police can take you home" 3. Put a hand on her shoulder and say, "It wasnt your fault" 4. Say, "Your mother is not going to kill you. Stop worrying"

1

What would be the appropriate first nursing action when caring for a 20 year old G1P0 woman at 39 weeks who is in active labor and for whom an assessment reveals mild variable FHR decelerations? 1. Change the maternal position 2. Notify the provider 3. Prepare for delivery 4. Readjust the fetal monitor

1

A 30 year old G6P5 woman at 12 weeks has just begun prenatal care, and her initial laboratory work reveals that she has tested positive for HIV infection. What would be priority evidence based nursing education for this patient today? 1. Medication for HIV infection is safe and can greatly reduce transmission of HIV to the infant 2. Breast feeding is still recommended due to the great benefits to the infant 3. Pregnancy is known to accelerate the course of HIV disease in the mother 4. C/s is not recommended because of the increased risk of HIV transmission with the bleeding at surgery

1

A client is scheduled to have surgery to relieve an intestinal obstruction. The nurse receives the following prescriptions for the client. Which of the following prescriptions should the nurse question before performing? 1. Tap water enemas until clear 2. Out of bed as tolerated 3. Neomycin sulfate 1 g PO every 4 hours 4. Betadine scrub to abdomen

1

A client who underwent an abdominal hysterectomy 3 days ago reports burning with urination. Her urine output during the previous shift was 210 mL, and her temp is 101.3/38.5. Which of these actions prescribed by the HCP will you implement first? 1. Insert a straight catheter PRN for output of less than 300 mL/8 hr 2. Administer Tylenol 650 mg orally 3. Send a urine specimen to the laboratory for culture and sensitivity testing 4. Administer cetizoxime (Cefizox) 1 g IV every 12 hours

1

A loading doses of digoxin is given to a client newly diagnosed with atrial fibrillation. the nurse instructs the client about the medication and the importance of monitoring his heart rate. An expected outcome of this instruction is: 1. A return demonstration of palpating the radial pulse 2. A return demonstration of how to take the medication 3. Verbalization of why the client has atrial fibrillation 4. Verbalization of the need for the medication

1

A multigravid client at 34 weeks gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of PPROM and preterm labor. The client's contractions are 20 minutes apart, lasting 20-30 seconds. Her cervix is dilated 2 cm. The nurse reviews the physician prescriptions. WHich of the following should the nurse initiate first? 1. Initiate fetal and contraction monitoring 2. Start IV infusion of D5LR 3. Obtain urine specimen 4. Administer betamethasone

1

A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. Which of the following should the nurse instruct the client to do? 1. Take the med immediately 2. Restart the med in the morning 3. Use another form of contraception for 2 weeks 4. Take 2 pills tonight before bedtime

1

After a radical prostatectomy, a client is ready to be discharged. Which nursing action included in the discharge plan should be delegated to an experienced LPN? 1. Reinforcing the client's need to check his temperature daily 2. Teaching the client how to care for his retention catheter 3. Documenting a discharge assessment in the client's chart 4. Instructing the client about the prescribed narcotic analgesic

1

After arriving for your shift in the ED, you receive a change of shift report about all of these clients. Which one do you need to assess first? 1. 19 year old with scrotal swelling and severe pain that has not decreased with elevation of the scrotum 2. 25 year old who has a painless indurated lesion on the glans penis 3. 44 year old with an elevated temp, chills, and back pain associated with recurrent prostatitis 4. 77 year old with abdominal pain and acute bladder distention

1

After testing a primigravid client at 10 weeks gestation about the recommendations for exercise during pregnancy, which of the following client statement indicates successful teaching? 1. While pregnant, I should avoid contact sports 2. Even though im pregnant, i can learn to ski next month 3. WHile we are on vacation next month, I can continue to scuba dive. 4. Sitting in a hot tub after exercise will help me to relax

1

After undergoing a modified radical mastectomy, the client is transferred to the PACU. Which nursing action is best to delegate to an experienced LPN? 1. Monitoring the client's dressing for any signs of bleeding 2. Documenting the initial assessment on the client's chart 3. Communicating the client's status report to the charge nurse on the surgical unit 4. Teaching the client about the importance of using pain medication as needed

1

The nurse collects a urine specimen from a client for a culture and sensitivity analysis. WHich of the following is the correct care of the specimen? 1. Promptly send the specimen to the laboratory 2. Send the specimen with the next pickup 3. Send the specimen the next time a nursing assistant is available 4. Store the specimen in the refrigerator until it can be sent to the laboratory

1

The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish speaking only client with an infant who is in the special care nursery (SCN) for fetal distress. The nurse should place the new client in a room with which of the following clients? 1. A G4 P4 who is 2 days postpartum with infant, Spanish speaking only 2. A G1 P1 who is 1 day postpartum with an infant in the SCN 3. A G6 P6 who delivered 4 hours ago by c/s for fetal distress, infant at bedside 4. A G1 P1 who is a non-English speaking client with infant in SCN for fetal distress

1

The nurse recognizes that a client with pain disorder is improving when the client says which of the following? 1. I need to have a good cry about all the pain Ive been in and then not dwell on it 2. I need to find another condition who can accurately diagnose my condition. 3. The pain medicine that you gave me helps me to relax 4, Im angry with all of the doctors Ive seen who don't know what theyre doing

1

The nurse walks into the room of a client who has a DNR prescription and finds the client without a pulse, respirations or BP. The nurse should first? 1. Stay in the room and call the nursing team for assistance 2. Push the emergency alarm to call a code 3. Page the client's physician 4. Pull the curtain and leave the room

1

The physician has prescribed a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical-surgical floor but the nurse assigned to the client has not been trained to handle chemotherapy agents. WHat is the nurse's most appropriate response? 1. Send the client to the oncology floor for administration of the medication 2. Ask a nurse from the oncology floor to come to the client and administer the medication 3. Ask another nurse to help mix the chemotherapy agent 4. Ask the pharmacy to mix the chemotherapy agent and administer it

1

The son of a client with Alzheimer's disease excitedly tells the nurse, "Mom was singing one of her favorite old songs. I think she's getting her memory back!" WHich of the following responses by the nurse is most appropriate? 1. She still has long-term memory, but her short-term memory will not return. 2. Im so happy to hear that. Maybe she is getting better. 3. Dont get your hopes up. This is only a temporary improvement. 4. Im glad she can sing even if she cant talk to you.

1

What would be accurate and priority information to give Ms N about the positive chlamydia test result? 1. By taking the medication now and having her partner treated, she can help avoid complications in the pregnancy. 2. The medication for chlamydia infection is not safe in pregnancy, and she should use condoms until she can be treated postpartum 3. Chlamydia infection cannot really be cured and may recur despite treatment 4. Chlamydia infection does no harm to the baby during the pregnancy or at delivery, but treatment is recommended to avoid PID in the woman

1

When performing chest percussions on a child, which of the following techniques should the nurse use? 1. Firmly but gently striking the chest wall to make a popping sound 2. Gently striking the chest wall to make a slapping sound 3. Percussing over an area from the umbilicus to the clavicle 4. Placing a blanket between the nurses hand and the childs chest

1

Which of the following factors is most important for healing an infected decubitus ulcer? 1. Adequate circulatory status 2. Scheduled periods of rest 3. Balanced nutritional diet 4. Fluid intake of 1500 mL/day

1

Which of the following is an appropriate outcome for a client with rheumatoid arthritis? 1. The client will manage joint pain and fatigue to perform activities of daily living 2. The client will maintain full range of motion in joints 3. The client will prevent the development of further pain and joint deformity 4. The client will take anti-inflammatory medications as indicated by the presence of disease symptoms

1

Which task could be appropriately assigned to the UAP working with you at the obstetric clinic? 1. Checking the BP of a patient who is 36 weeks pregnant and reports a headache 2. Removing the adhesive skin closure strips of a patient who had a cs 2 weeks ago 3. Giving community resource information and emergency numbers to a prenatal patient whom you suspect is experiencing domestic violence 4. Dispensing a breast pump with instruction to a lactating patient having trouble with milk supply 4 weeks postpartum

1

You are the charge nurse in the L&D unit. Which action by a newly graduated RN during a delivery complicated by shoulder dystocia would require your immediate intervention? 1. Applying fundal pressure 2. Applying suprapubic pressure 3. Requesting immediate presence of the neonatologist 4. Flexing the maternal legs back across the maternal abdomen

1

You are working as a telephone triage nurse in the prenatal clinic. Which telephone call would require immediate notification of the provider? 1. Patient reports leaking vaginal fluid at 34 weeks 2. Pt reports n/v at 8 weeks 3. Pt. reports pedal edema at 39 weeks 4. Pt reports vaginal itching at 20 weeks

1

You are working in the ED when a client with possible TSS is admitted. Which prescribed intervention will you implement first? 1. Remove the client's tampon 2. Obtain blood specimens for culture 3. Give Tylenol 650 mg 4. Infuse nafcilling (Unipen) 1000 mg IV

1

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistuala (TEF) for which of the following? Select all that apply 1. Copious frothy mucus 2. Episodes of cyanosis 3. Several loose stools 4. Initial weight loss 5. Poor gag reflex

1, 2

You have received orders to initiate phototherapy on a 36 year old newborn with an elevated bilirubin level. What instructions will you give the student nurse who is assisting in the care of the infant? Select all that apply 1. Cover the infant's eyes with a mask 2. Monitor the infant's temperature closely 3. Keep the infant NPO during the treatment 4. Apply ointment to the infant's skin prior to light exposure 5. Offer the infant sterile water feedings during the treatment

1, 2

A client with severe osteoarthritis and decreased mobility is transferred to an assisted living facility. The nurse notices that the client smells of alcohol, exhibits an unsteady gait and has six wine bottles in the trash. The client tells the nurse, "Those are my other pain medicines" Which of the following statements by the nurse are most appropriate? Select all that apply. 1. I didn't realize that your pain was not being managed with your current medications 2. It is important for me to know how many bottles of wine you drank this week. 3. Im worried about the amount of wine you are drinking and its effect on your balance. 4. How are you getting all this wine? 5. I am calling your doctor to have all of us to talk about better pain control without the wine.

1, 2, 3, 5

A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply 1. Excessive alcohol use 2. Gallstones 3. Abdominal trauma 4. HTN 5. Hyperlipidemia with excessive triglycerides 6. Hypothyroidism

1, 2, 3, 5

What would be your priority topics in client teaching today? Select all that apply 1. Smoking cessation methods 2. Recommendation of a flu shot (if flu season) 3. Danger signs during pregnancy 4. Basics of nutrition 5. Pain relief options in labor and birth

1, 2, 3,4

Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply 1. Accepting the client while not arguing with the delusion 2. Focusing on the feelings or meaning of the delusion 3. Focusing on events and topics based in reality 4. Confronting the client's beliefs 5. Interacting with the client only when the client is based in reality

1, 2, 3. For the client with grandiose, the nurse should accept the client but not argue with the delusion to build trust and the client's self-esteem. Focusing on the underlying feeling or meaning of the delusion helps to meet the client's needs. Focusing on events and topic based in reality distracts the client from delusional thinking. Confronting the client's delusions or beliefs can lead to agitation in the client and the need to cling to the grandiose delusion to preserve self-esteem. Interacting with the client only when based in reality ignores the client's needs and therapeutic nursing interventions.

Which of the following statements made by a pregnant woman in the first trimester are consistent with this stage of pregnancy? Select all that apply 1. My husband told his friends we will have to give up the Mustang for a minivan. 2. Oh my, how did this happen? I don't need this now. 3. I cant wait to see my baby. Do you think it will have my blond hair and blue eyes? 4. I used a Disney theme for decorating the room 5. I wonder how it will feel to buy maternity clothes and be fat. 6. We went to a mall yesterday to buy a crib and dressing table.

1, 2, 5 The first trimester is when the couple works through the psychological task of accepting the pregnancy. These statements describe the client and her partner coping with the pregnancy, how it feels and how it will impact their lives. the feelings include pleasure, excitement and ambivalence. Wondering what the baby will look like and planning for the baby's room occur later in the pregnancy.

A student nurse is helping you to prepare for Ms N's discharge. Which statement made to Ms N by the student would require you to intervene and correct the information given? 1. The iron may cause constipation 2. The iron should be taken daily with milk 3. The iron may cause darkening of the stools 4. The iron does not take place of a high iron diet, which should also be followed

2

After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply 1. I will avoid eating meat for 1-3 days before getting a stool sample 2. I need to eat foods low in fiber a few days before collecting the sample 3. Ill take the sample from different areas of the stool that I have passed. 4. I need to send the stool sample to the lab in a covered container right away 5. I can continue to take all of my regular medications at home

1, 3

A 19 year old G1P0 patient at 40 weeks who is in labor is being treated with mag sulfate for seizure prophylaxia in preeclampsia. Which are priority assessments with this medication? Select all that apply 1. Check deep tendon reflexes 2. Observe for vaginal bleeding 3. Check the RR 4. Note the UP 5. Monitor for calf pain

1, 3, 4

Which statements by a new father indicate that additional discharge teaching is needed for this family, who had their first baby 24 hours ago? Select all that apply 1. We have a crib ready for our baby with lots of stuffed animals and two quilts that my mother made 2. My wife wants to receive the flu shot before she goes home 3. We will bring our baby to the pediatrician in 3 weeks 4. I will give you the baby formula at night so my wife can rest. She will breast-feed in the daytime 5. We will always put our baby to sleep in a face-up position

1, 3, 4

A 24 year old G1P0, who is receiving Pitocin is in labor at 41 weeks. Which are appropriate nursing actions in the presence of late FHR decelerations? Select all that apply 1. Discontinue the oxytocin 2. Decrease the maintenance IV fluid rate 3. Administer oxygen to the mother by mask 4. Place the woman in high Fowler position 5. Notify the provider

1, 3, 5

As the charge nurse in the L&D unit, you need to assign two patients to one of the RNs because of a staffing shortage. Normally on your unit the nurse-pt ratio is 1:1. Which 2 patients will you assign to the RN? 1. 30 year old G1P0, 40 weeks, 2 cm/90% effaced, -1 station 2. 25 year old G3P2, 38 weeks, 8 cm/100% effaced, 0 station 3. 26 year old G1P1 who delivered via normal vaginal delivery 15 minutes ago 4. 17 year old G1P0 with PROM, no labor at 35 weeks 5. 40 year old G6P5 with contractions at 28 weeks who has not yet been evaluated by the provider

1, 4

A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg BID and lamotrigine (Lamictal) 25 mg BID, Which of the following adverse effects should the nurse report to the physician immediately? Select all that apply. 1. Rash 2. Nausea 3. Sedation 4. Hyperthermia 5. Muscle rigidity

1, 4, 5. Lamotrigine, an antiepileptic, is used as a mood stabilizer for clients with bipolar disorder and has been found to be effective for the depressive phase of bipolar disorder. COmmon adverse effects are dizziness, headache, sedation, tremors, nausea, vomiting and ataxia. The development of a rash needs to be reported and evaluated by the physician because it could indicate the start of Stevens-JOhnson syndrome, a toxic epidermal necrolysis, which would necessitate the discontinuation of lamotrigine. Hyperthermia in conjunction with muscle rigidity suggests the development of neuroleptic malignant syndrome, a life-threatening complication associated with olanzapine.

Which of the following responses is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away? 1. When you interrupt others, they leave the area 2. You are being rude and uncaring 3. You should remember to use your manners 4. You know better than to interrupt someone

1. Saying this is most helpful because it serves to increase the client's awareness of others' perceptions of the behavior by giving specific feedback abut the behavior. The other statements are punitive and authoritative, possibly threatening to the client, and likely to increase defensiveness, decrease self-worth, and increase feelings of guilt.

When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier: 1. Provides an outlet for emotional tension 2. Indicates readiness to take solid foods 3. Indicates intestinal motility 3. is an attempt to get attention from the parents

1. Sucking provides the infant with a sense of security and comfort. It is also an outlet for releasing tension. the infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant's appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention

An infant is born with facial abnormalities, growth retardation, mental retardation and vision abnormalities. These abnormalities are likely caused by maternal: 1. Alcohol consumption 2. Vitamin B6 deficiency 3. Vitamin A deficiency 4. Folic acid deficiency

1. These effects and others when seen after birth are known as a cluster of symptoms called fetal alcohol syndrome. Vitamin B6 and vitamin A deficiency can affect growth and development but not with these specific side effects. Folic acid deficiency contributes to neural tube defects.

A client asks the nurse how long it will be necessary to take the medicine for hypothyroidism. The nurse's response is based on the knowledge that: 1. Lifelong daily medicine is necessary 2. The medication is expensive and the dose can be reduced in a few months 3. The medication can be gradually withdrawn in 1-2 years. 4. The medication can be discontinued after the client's TSH level is normal

1. Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid supplementation to maintain health. The medication cannot be discontinued after the TSH level is normal; the dose will be maintained at the level that normalizes the TSH concentration.

A client with major depression states, "Life isn't worth living anymore. Nothing matters." Which of the following responses by the nurse is best? 1. Are you thinking about killing yourself? 2. Things will get better, you know. 3. Why do you think that way? 4. You shouldn't feel that way.

1. When the client verbalizes that life isn't worth living anymore, the nurse needs to ask the client directly about suicide. Asking directly does not provoke suicide but conveys concern, understanding, and the worth of the client. Commonly the client experiences a sense of relief that someone finally hears him. It also helps the nurse plan responsible care by identifying a client at risk.

A 27 year old patient underwent a primary cs because of breech presentation 24 hours ago. Which assessment finding would be of the most concern? 1. Small amount of lochia rubra 2. Temp of 99/37.2 3. Slight redness of the left calf 4. Pain rated as 3/10 in incisional area

3

A client with delirium becomes very anxious and says, "I cant stop what is happening to me. Make it stop please!" Which of the following responses is the nurse's most appropriate response? 1. Ill get you some medicine to help you relax. The more you worry, the worse it will get. 2. As soon as we know what's causing this, we can try to stop it. Ill get you some medicine to help you relax 3. I wish i could do something to make it stop, but unfortunately i cant. 4. Ill sit with you until you calm down a little

2

A 23 year old G1P0 patient at 10 weeks states that she exercises 5 days a week. You have discussed exercise in pregnancy with her. Which statement by the patient indicates that more teaching of evidence-based principles is needed? 1. I will continue to exercise 5 days a week 2. I will reduce my exercise at this time in my pregnancy to reduce the risk of miscarriage but will increase it in the 2nd trimester 3. I will drink more fluid before and after exercising 4. I will stop playing football while I am pregnant

2

A 24 year old G2P1 woman is being admitted to active labor at 39 weeks. What prenatal data would be most important to know in your care of this patient at this time? 1. Hemoglobin level of 11 g/dL at 28 weeks 2. Positive result on test for group B streptococci at 36 weeks 3. Urinary tract infection with E coli treated at 20 weeks 4. Elevated level on glucose screening test at 28 weeks followed by normal 3 hour glucose tolerance test at 29 weeks

2

A client has been prescribed hydrochlorothiazide (HCTZ) to treat heart failure. For which of the following symptoms should the nurse monitor the client? 1. Urinary retention 2. Muscle weakness 3. COnfusion 4. Diaphoresis

2

A client in cardiac rehabilation would like to eat the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity? 1 Protein 2. Carbohydrate 3. Fat 4. Water

2

An 86 year old woman had an anterior and posterior colporrhaphy (A&P repair) several days ago. Her retention catheter was removed 8 hours ago. Which assessment finding requires that you act most rapidly? 1. The oral temp is 100.7/38.2 2.. The abdomen is firm and tender to palpation above the symphysis pubis 3. Breath sounds are decreased, with fine crackles audible at both bases 4. The apical pulse is 86 bpm and slightly irregular

2

The nurse hears a pregnant client yell, "Oh my! The baby's coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse see that the neonate's head is delivering. Which of the following should the nurse do first? 1. Suction the mouth with two fingertips 2. Check for presence of a cord around the neck 3. Tell the client to bear down with force 4. Advise the mother that help is on the way

2

The nurse is preparing a discharge plan for a 16 year old client who has fractured the femur and ulna. The client asks the nurse how quickly the fractures will heal. Which of the following responses is most appropriate for the nurse to make? 1. The healing of your leg will be delayed because you have had skeletal traction. 2. It will take your arm about 12 weeks to heal but it will take your leg about 24 weeks 3. Because you are young and healthy, your bones should heal in less than 12 weeks 4. You will require long-term rehabilitation and should expect it to take at least 8 months for your bones to heal.

2

Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. You find that the wound edges are open and loops of intestine are protruding. Which action should you take first? 1. Notify the surgeon that wound evisceration has occurred 2. Cover the wound with saline-soaked dressings 3. Use swabs to obtain aerobic and anaerobic wound cultures 4. Call for assistance from the Rapid response team

2

What else would be a priority given the scenario described earlier? 1. Instruct Ms. N not to fast for the 3 hour glucose tolerance test because it is not safe to do so in pregnancy 2. Refer Ms N to a social worker because her increased stress can be a risk factor for preterm birth 3. Instruct Ms N that HPV infection can be effectively treated with colposcopy 4. Instruct Ms N that, if HPV is present at the time of labor, a cs will be needed

2

When assessing a client with cervical cancer who had a total abdominal hysterectomy yesterday, you obtain the following data. Which information has the most immediate implications for planning of the client's care? 1. Fine crackles are audible at the lung bases 2. The client's right calf is swollen and she reports calf tenderness 3. The client uses the PCA every 30 minutes 4. Urine in the collection bag is amber and clear

2

Which action would best demonstrate evidence-based nursing practice in the care of a patient who is 1 day postpartum and reporting nipple soreness while breastfeeding? 1. Give the baby a bottle after 5 minutes of nursing to allow soreness to resolve 2. Assess the mother-baby couplet for nursing position and latch, and correct as indicated 3. Advise the use of a breast pump until nipple soreness resolves 4. Advise alternating breast and bottle feedings to avoid excess sucking at the nipple

2

Which of the following is an adverse effect of vancomycin and needs to be reported promptly? 1. Vertigo 2. Tinnitus 3. Muscle stiffness 4. Ataxia

2

While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out but theyre still there" After assessing the neonate's mouth, the nurse explains that these spots are which of the following? 1. Koplik's spots 2. Epstein's pearls 3. Precocious teeth 4. Thrush curds

2

You are caring for a client who has just returned to the surgical unit after a TURP. Which assessment finding will require the most immediate action? 1. BP reading of 153/88 mm Hg 2. Catheter that is draining deep red blood 3. Client not wearing antiembolism hose 4. Client reports of abd. cramping

2

You are working with a UAP to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can you delegate to the UAP? 1. Teaching the client why blood pressure measurements are taken on the left arm 2. Elevating the client's arm on two pillows to promote lymphatic drainage 3. Assessing the client's right arm for lymphedema 4.Reinforcing the dressing if it becomes saturated

2

A 79 year old who has just returned to the surgical unit following a TURP reports acute bladder spasms. In which order will you perform the following prescribed actions? 1. Administer 2 tablets Percocet 325/5 2. Irrigate the retention catheter with 30-50 mL of sterile NS 3. Infuse 500 mL of 5% dextrose in LR solution over 2 hours 4. Offer the client oral fluids to at least 2500-3000 mL daily

2, 1, 3, 4

A 36 year old G1P0 has received an epidural anesthetic. Her cervix is 6 cm dilated. Her BP is currently 60/38 mm Hg. Which would be appropriate priority nursing actions? Select all that apply 1. Place the patient in high Fowler position 2. Turn the patient to a lateral poisiton 3. Notify the anesthesiologist 4. Prepare for emergency cs 5. Decrease the IV fluid rate

2, 3

What would be priority data for the RN to obtain before giving Ms N advice by phone? Select all that apply 1. Did she take her vitamin and iron today? 2. What are the frequency and intensity of the contractions? 3. Is there vaginal bleeding? 4. Did her water break? 5. How far does Ms N live from the hospital?

2, 3, 4, 5

A 30 year old G1P0 at 39 weeks experienced a fetal demise and has just delivered a female infant. Her husband is at the bedside. Which are appropriate nursing actions at this time? Select all that apply 1. Offer the option of autopsy to the parents 2. Stay with the parents and offer supportive care 3. Place the infant on the maternal abdomen 4. Clean and wrap the baby and offer the infant to the parents to view or hold when desired 5. Ask the parents if there are any special rituals in their religion or culture for a baby who has died that they would like to have done

2, 4, 5

When you are developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will you delegate to the home health aide? Select all that apply 1. Monitoring the client for symptoms of urinary tract infection 2. Helping the client to connect the catheter to the leg bag 3. Checking the client's incision for appropriate wound healing 4. Assisting the client in ambulating for increasing distances 5. Helping the client shower at least every other day

2, 4, 5

A client takes hydrochlorthiazide (HCTZ) for treatment of hypertension. The nurse should instruct the client to report which of the following? Select all that apply. 1. Muscle twitching 2. Abdominal cramping 3.Diarrhea 4. Confusion 5. Lethargy 6. Muscle weakness

2, 5, 6 HCTZ is a thiazide diuretic used in the management of mild to moderate HTN and in the treatment of edema associated with heart failure, renal dysfunction, cirrhosis, corticosteroid therapy, and estrogen therapy. It increases the excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule of the kidneys. It promotes the excretion of chloride, potassium, magnesium and bicarbonate. Side effects include drowsiness, lethargy, and muscle weakness but not muscle twitching, Although there may be abdominal cramping, there is no diarrhea. The client does not become confused as a result of taking this drug.

Which finding requires immediate intervention when planning care for an adolescent with CF? 1. Delayed puberty 2. Chest pain with dyspenea 3. Poor weight gain 4. Large foul-smelling bulky stools

2. Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance with taking enzymes and should be addressed but respiratory complications are the greatest concern.

When a client wants to read the chart, the nurse should 1. Call the health care provider to obtain permiossion 2. Give the client the chart and answer the client's questions 3. Tell the client to read the chart when the doctor makes rounds 4. Answer any questions the client has without giving the client the chart

2. The client should be allowed to see the chart. As a client advocate, the nurse should answer questions for the client. The nurse helps the client become a primary partner in the health team. The Bill of Rights for patients has existed since the 1960s and every client should be aware of this document. The doctor should not need to give permission for the client to see the chart. As a client advocate, the nurse should not make excuses to put the client off in regard to seeing the chart.

The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms? 1. Sore throat and muscle aches. 2. Nausea and flushing of the face and neck 3. Fever and muscle soreness 4. Bradycardia and vertigo

2. The client who drinks alcohol while taking disulfiram experiences sweating, flushing of the neck and face, tachycardia, hypotension, a throbbing headache, nausea and vomiting, palpitations, dyspnea, tremor and weakness.

A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best? 1. Would you like me to help you tell them? 2. The information you confide in me is confidential. 3. I must share this information with your family. 4. I mist share this information with your employer.

2. The nurse is responsible for maintaining confidentiality of this disclosure by the client

An elderly client is being admitted to same day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that 1. The rings will be taped before the surgery 2. The rings will be placed in an envelope, the client will the envelope and the envelope will be placed in a safe. 3. The rings will be locked in the narcotics box 4. The nursing supervisor will hold onto the rings during the surgery.

2. Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables

A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. WHich of the following instructions should the nurse give the client in response to this information? 1. Anticipate lesions within 25-30 days 2. COntinue sexual activity unless lesions are present 3. Report any difficulty urinating 4. Drink extra fluids to prevent lesions from forming

3

A client who is on NPO status is constantly asking for a drink of water. Which of the following is the most appropriate nursing intervention? 1. Reexplain why it is not possible to have a drink of water 2. Offer ice chips every hour to decrease thirst 3. Offer the client frequent oral hygiene care 4. Divert the client's attention by turning on the tv

3

A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. The fluctuation means that: 1. There is an obstruction in the chest tube 2. The client is developing subcutaneous emphysema 3. The chest tube system is functioning properly 4. There is a leak in the chest tube system

3

A pregnant woman at 12 weeks tells you that she is a vegetarian. What would be the first appropriate nursing action? 1. Recommend vitamin B12 and iron supplementation 2. Recommend consumption of protein drinks daily 3. Obtain a 24 hour diet recall history 4. Determine the reason for her vegetarian diet

3

A 17 year old G1P0 woman at 40 weeks is in labor. She has chosen natural childbirth with assistance from a doula. Her mother and her boyfriend are at the bedside. What nursing action can help the patient achieve her goal of an unmedicated labor and birth? 1. Encourage the patient to stay in bed 2. Allow the patient's support people to provide labor support and minimize nursing presence 3. Assess the effectiveness of the labor support team and offer suggestions as indicated 4. Offer pain medication on a regular basis so the patient knows it is available if desired

3

A 22 year old is 6 weeks postpartum. In the clinic she admits to crying every day, feeling overwhelmed and sometimes thinking that she may hurt the baby. What would be the priority nursing action at this time? 1. Advise the patient of community resources, parent groups, and depression hotlines 2. Counsel the mother that the "baby blues" are common at this time and assess her nutrition, rest and availability of help at home 3. Contact the provider to evaluate the patient before allowing her to leave the clinic 4. Advise the woman that she cannot use medication for depression because she is breast feeding

3

A 25 year old G2P1 patient has come to the obstetric triage room at 32 weeks reporting painless vaginal bleeding. You are providing orientation for a new RN on the unit. Which statement by the new RN to the patient would require your prompt intervention? 1. Im going to check your VS 2. Im going to apply a fetal monitor to check the baby's heart rate and to see if you are having contractions 3. Im going to perform a vaginal examination to see if your cervix is dilated 4. Im going to feel your abdomen to check the position of the baby

3

The client with a NG tube has abdominal distention. Which of the following measures should the nurse do first? 1. Call the physician 2. Irrigate the NG tube 3. Check the function of the suction equipment 4. Reposition the NG tube

3

The nurse is beginning the shift and is planning care for 6 clients on the postpartum unit. Three of the clients are listed as stable. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first? 1. The three clients reported to be stable 2. The mother with a 4 hour old infant with initial blood glucose of 33 mg/dL and now at 45 mg/dL breast-feeding her infant 3. A mother who had a spontaneous vaginal delivery and received methlergonovine maleate (Methergine) 1 hour ago for increased bleeding. 4. A mother with a 3 day old infant who had a bilirubin level of 13 mg/dL 30 minutes ago and is now in a biliblanket at the mothers bedside

3

The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below (palpating the head which is nearest the cervix and is the presenting part). Which of the following maneuvers is the nurse performing? 1. First maneuver 2. 2nd 3. 3rd 4. 4th

3

The nurse should assess the client with severe acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3

What priority information would be important to give Ms N about this treatment? 1. THe procardia and betamethasone work together to help stop preterm labor 2. The Procardia is to prevent neonatal heart problems after birth and the betamethason is to stop contractions 3. The betamethasone is to help the infant's lungs mature and to try to prevent other neonatal complications in case the infant is born early. The Procardia is to attempt to stop the contractions. 4. The Procardia is to treat chlamydia infection and the betamethasone is to help the infant's lungs mature.

3

When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches? 1. Questioning the client about how much alcohol the client consumes each day 2. Confronting the client about being intoxicated 2 days ago 3. Pointing out how alcohol has gotten the client into trouble 4. Listening to what the client states and then asking the client about plans for staying sober

3

Which information obtained when taking a client's health history will be most important in determining whether the client should receive the HPV immunization? 1. Client is 19 years old 2. Client is sexually active 3. Client has a positive pregnancy test 4. CLient has tested positive for HPV previously

3

Which of the following findings should the nurse note in the client who is in the compensatory stage of shock? 1. Decreased urinary output 2. Significant hypotension 3. Tachycardia 4. Mental confusion

3

Which tasks to prepare for Ms N's discharge could be delegated to a UAP? 1. TEaching Ms N the signs of preterm labor 2. Discussing nutrition, smoking cessation and stress reduction 3. Calling the prenatal clinic to schedule the next prenatal appt within 1 week 4. Calling a social worker to discuss a plan of care given the history of domestic violence

3

While assessing a 29 year old G2P2 patient who had a normal spontaneous vaginal delivery 30 minutes ago, you note a large amount of red vaginal bleeding. What would be your first priority nursing action? 1. Check VS 2. Notify the provider 3. Firmly massage the uterine fundus 4. Put the baby to breast

3

You are assessing a long-term care client with a history of BPH. Which information will require the most immediate action? 1. The client states that he always has trouble starting his urinary stream 2. The chart shows an elevated level of PSA 3. The bladder is palpable about the symphysis pubis and the client is restless 4. The client says he has not voided since having a glass of juice 4 hours ago

3

You are providing orientation for a new RN on the med-surg unit. The new RN takes the following actions while caring for a client with severe PID. Which action by the new RN is most important to correct quickly? 1. Telling the client that she should avoid using tampons in the future 2. Offering the client an ice pack to decrease her abdominal pain 3. Positioning the client flat in bed while helping her take a bath 4. Teaching the client that she should not have intercourse for 2 months

3

You are the charge nurse on the oncology unit. Which client is best to assign to an RN who has floated from the ED? 1. Client who needs doxorubicin (Adriamycin) to treat metastatic breast cancer 2. Client who needs discharge teaching after surgery for stage II ovarian cancer 3. Client with metastatic prostate cancer who requires frequent assessment and treatment for breakthrough pain 4. Client with testicular cancer who requires preoperative teaching about orchiectomy and lymph node resection

3

You are working on a medical unit staffed with LPNs and UAPs when a client with state IV ovarian cancer and recurrent ascites is admitted for paracentesis. Which activity is best to delegate to an experienced LPN? 1. Obtaining a paracentesis tray from the central supply area 2. Completing the short stay client admission form 3. Measuring VS every 15 mins after the procedure 4. Providing discharge instructions after the procedure

3

You observe a student nurse who is caring for a client who has an intracavity radioactive implant in place to treat cervical cancer. Which action by the student requires that you intervene immediately? 1. Standing next to the client for 5 minutes while assisting with her bath 2. Asking the client how she feels about losing her childbearing ability 3. Assisting the client to the bedside commode for a bowel movement 4. Offering to get the client whatever she would like to eat or drink

3

A 4 year old is brought to the emergency room with sudden onset of a temperature of 103 F, sore throat, and refusal to drink, The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next? 1. Give 600 mg of Tylenol rectally as prescribed 2. Inspect the child's throat for redness and swelling 3. Have an appropriate-sized tracheostomy tube readily available 4. Obtain a specimen for a throat culture

3. The child is exhibiting signs and symptoms of possible epiglottiditis. As a result, the child is at high risk for laryngospasm and airway occlusion. Therefore, the nurse should have a trach tube and setup readily available should the child experience an airway occlusion. Although acetaminophen is an antipyretic, the dosage of 600 mg rectally is too high. A typical 4 year old weighs about 40 pounds. The recommended dose is 125 mg. When any type of respiratory illness and especially epiglottiditis, is suspected, putting any object, including a tongue depressor for inspection or a cotton-tipped applicator to obtain a throat culture, in the back of the mouth or throat or having the child open the mouth is inappropriate because doing so may predispose the child to laryngospasm or occlusion of the airway by a swollen epiglottis

A client admitted with a gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL and blood pressure is 100/50 mm Hg. The client and family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the physician and the family to next: 1. Discontinue all measures 2. Notify the hospital attorney 3. Attempt to stabilize the client through the use of fluid replacement 4. Give enough blood to keep the client from dying

3. The most appropriate response is to continue all treatments and attempt to stabilize the client using fluid replacement without administering blood or blood products. It is imperative that the health care team respect the client's religious beliefs and wishes, even if they are not those of the health care team. Discontinuing all measures is not an option. The health care team should continue to provide the best care possible and does not need to notify the attorney.

A client has been taking imipramine (Tofranil) for depression for 2 days. His sister asks the nurse, "Why is he still so depressed?" Which of the following responses is the most appropriate? 1. Your brother is experiencing a very serious depression 2. Ill be sure to convey your concern to his physician. 3. It take 2-4 weeks for the drug to reach its full effect 4. Perhaps we need to change his medication

3. The nurse needs to inform the sister that it takes 2 to 4 weeks before a full clinical effect occurs with the drug. The nurse should let her know that her brother will gradually get better and symptoms of depression of depression will improve.

A client with a fractured leg has been instructed to ambulate without weight bearing on the affected leg. The nurse evaluates that the client is ambulating correctly if the client uses which of the following crutch-walking gaits? 1. Two-point gait 2. Four-point gait 3. Three point gait 4. Swing to gait

3. The three-point gait, in which the client advances the crutches and the affected leg at the same time while weight is supported on the unaffected extremity, is the appropriate gait of choice. This allows for non-weight bearing on the affected extremity. The two-point, four-point, and swing-to gaits require some weight bearing on both legs, which is contraindicated for this client.

A 3 day old breast fed infant is brought to the clinic for routine assessment following a normal full-term delivery without complications. Which statement by the parents suggests an abnormal finding on a newborn of this age? 1. The baby urinated only 3 times yesterday 1. The bowel movement of the baby was dark at first, but yesterday it was greenish yellow 3, The baby cried for 2 hours last night 4. The baby ate four times in the past 24 hours

4

A 30 year old woman with Type 1 DM comes to the clinic for preconception care. What is the priority education for her at this time? 1. Her insulin requirements will likely increase during the second and third trimesters of pregnancy 2. Infants of diabetic mothers can be macrosomic, which can result in more difficult delivery and higher likelihood of cs 3. Breast feeding is highly recommended and insulin use is not a contraindication 4. Achievement of optimal glycemic control at this time is of utmost importance in preventing congenital anomalies

4

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. Which of the following is the nurse's best response? 1. What has your neighbor doing that bothers you? 2. How long have you been hearing these terrible voices? 3. We wont let your neighbor visit so youll be safe 4. What exactly are these terrible voices saying to you?

4

A client has the leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment? 1. Inability to move toes 2. Cyanosis of toes 3. Sensation of cast tightness 4. Tingling of toes

4

A client with diabetes is explaining to the nurse how to care for the feet at home. Which statement indicates that the client understands proper foot care? 1. When I injure my toe, I will plan to put iodine on it 2. I should inspect my feet at least once a week 3. It is okay to go barefoot in the house 4. It is important to dry my feet carefully after my bath

4

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. WHich of the following interventions should be included in the plan of care before hydrotherapy treatment is initiated? 1. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting 2. Increase the IV flow rate to offset fluids lost through the therapy 3. Apply a topical antibiotic cream to burns to prevent infection 4. Administer pain medication 30 minutes before therapy to help manage pain

4

A full term newborn is at the clinic with his parents. He is 4 days old. His birth weight was 7 pounds. Which assessment made by the RN is most significant? 1. The infant's weight today is 6 lb 9 oz 2. The infant's skin is peeling 3. The infant's breast tissue is swollen 4. There is a yellow discharge from the infant's right eye

4

A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following? 1. Varicocele 2. Frequent use of saunas 3. Endocrine imbalances 4. Decreased body temperature

4

A nurse is planning care for a client who has heart failure. Which goal is appropriate for a client with excess fluid volume? 1. A weight reduction of 10% will occur 2. Pain will be controlled effectively 3. ABG values will be WNL 4. Serum osmolality will be WNL

4

The day after a radical prostatectomy, your client has blood clots in the urinary catheter and reports bladder spasms. The client says that his right calf is sore and that he feels short of breath. Which action will you take first? 1. Irrigate the catheter with 50 mL of sterile saline. 2. Administer oxybutynin (Ditropan) 5 mg orally 3. Apply warm packs to the client's right calf 4. Measure oxygen sat using pulse oximetry

4

While performing a breast examination on a 22 year old client, you obtain the following data. Which finding is of most concern? 1. Both breasts have many nodules in the upper outer quadrants. 2. The client reports bilateral breast tenderness with palpation. 3. The breast on the right side is slightly larger than the left breast. 4. An irregularly shaped, nontender lump is palpable in the left breast

4

While you are working in the clinic, a healthy 32 year old woman whose sister is a carrier of the BRCA gene asks you which form of breast cancer screening is the most effective for her. Which response is best? 1. An annual mammogram is usually sufficient screening for women your age. 2. Monthly self breast examination is recommended because of your higher risk 3. A yearly breast examination by a health care provider should be scheduled 4. Magnetic resonance imaging is recommended in addition to annual mammography

4

You are the RN in the L&D unit caring for a G3P2 pt. in active labor. You have identified late fetal heart decelerations and decreased variability in the FHR. You have notified the provider on call, who feels that the pattern is acceptable. What would be your priority action at this time? 1. Advise the patient that a different provider will be called because you do not agree with the advice of the first provider 2. Discuss your concerns with another L&D nurse 3. Document your conversation with the provider accurately, including the provider's interpretation and recommendation, and continue close observation of the FHR 4. Go up the chain of command and communicate your assessment of the FHR findings clearly to the next appropriate provider

4

You obtain the following assessment data about your client who has had a TURP and has continuous bladder irrigation. Which finding indicates the most immediate need for nursing interventions? 1. The client states that he feels a continuous urge to void 2. The catheter drainage is light pink with occasional clots 3. The catheter is taped to the client's thigh 4. The client reports painful bladder spasms

4

After you receive the change of shift report, in which order will you assess these clients assigned to your care? 1. 22 year old who has questions about how to care for the drains placed in her breast reconstruction incision 2. Anxious 44 year old who is scheduled to be discharged today after undergoing a total vaginal hysterectomy 3. 69 year old who reports level 5 pain (on 0-10 scale) after undergoing perineal prostatectomy 2 days ago 4. Usually oriented 78 year old who has new onset confusion after having a bilateral orchiectomy the previous day

4, 3, 2, 1

The nurse should advise which of the following clients who is taking lithium to consult with the physician regarding a potential adjustment in lithium dosage? 1. A client who continues work as a computer programmer 2. A client who attends college classes 3. A client who can now care for her children 4. A client who is beginning training for a tennis team

4. A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs and when a new diet begins.

A 68 year old client's daughter is asking about the follow-up evaluation for her father after pneumonectomy for primary lung cancer. The nurse's best response is which of the following: 1. The usual follow-up is chest x-ray and liver function tests every 3 months. 2. The follow-up for your father will be a chest x-ray and a computed tomography scan of the abdomen every year. 3. No follow-up is needed at this time. 4. The follow-up for your father will be a chest x-ray every 6 months

4. Follow-up generally involves semiannual chest radiographs. Recurrence usually occurs locally in the lungs and may be identified on chest radiographs. Follow-up after cancer treatment is an important component of the treatment plan. Serum markers (liver function tests) have not been shown to detect recurrence of lung cancer. There are no data to support the need for an abdominal computed tomography scan.

A 22 year old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate poisoning. Which of the following is appropriate for obtaining permission to place a catheter for ICP monitoring? 1. The nurse will obtain a signed consent from the client's fiancée because he is of legal age and they are engaged to be married. 2. The physician will get a consultation from another physician and proceed with placement of the ICP catheter until the family arrives to sign the consent. 3. Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. 3. The physician will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without a consent.

4. In a life threatening emergency where time is of the essence in saving life or limb, consent is not required.

NSAIDs are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to: 1. take NSAIDs at least 3 times per day 2. Exercise the joints at least 1 hour after taking the medication 3. Take antacids 1 hour after taking NSAIDs 4. Take NSAIDs with food

4. NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of NSAIDs.

The nurse is teaching a client about using topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching? 1. I will avoid being out in the sun for long periods 2. I should stop applying it once the infected area heals. 3. Ill call the physician if the condition worsens 4. I should apply it to large open areas

4. The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded areas because toxicity and systemic absorption are possible.

The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says: 1. If I think I have a bladder infection, I need to see my obstetrician. 2. If I have contractions, I should contact my HCP 3. Drinking water may help prevent early labor for me 4. If I travel on long trips, I need to get out of the care every 4 hours

4. Traveling is usually discouraged if preterm labor has been a problem, as it restricts normal movement. A client should be able to walk around frequently to prevent blood clots and to empty her bladder at least every 1-2 hours. Bladder infections often stimulate preterm labor and preventing them is of great importance to this client. COntractions that recur indicate the return of preterm labor, and the health care provider needs to be notified. Dehydration is known to stimulate preterm labor and encouraging the client to drink adequate amounts of water helps to prevent this problem