UNIT 1 REVIEW RNSG 2404

A nurse in antepartum clinic is caring for a client who is pregnant

-vag exam consistent with preterm -pain consistent with preterm and UTI -vag discharge is consistent with preterm -temp consistent with UTI

A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: HR 110/min, slow weak cry, some flexion of extremities, grimace in response to suctioning of the nares, body pink in color with blue extremities. Calculate Apgar score

6

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 mins after delivery. He has a weak and slow cry, HR of 130/min and cries in response to suctioning. The nurse should document what apgar score for this infant

8

A nurse is reviewing the lab results of a client who is postop. Which of the following lab finding should the nurse identify as an indication of postop infection? a. increase band neutrophils b. elevated erythrocyte sed rate c. absence of ketones in urine d. neg leu in urine e. increase hemoglobin

A, B

A nure is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include a. vit a b. vit b12 c. vit c d. vit d e. vit k

A, B, C, E

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? Select all that apply a. blot the perineal area dry after cleansing b. clean the perineal area from front to back c. perform hand hygiene before and after voiding d. apply ice pack to the perineal area several times daily e. wash the perineal area using a squeeze bottle of warm water after each voiding

A, B, C, E

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? Select all that apply a. poor nutritional state b. altered mental status c. obesity d. pain medicaton administration e. wound infection

A, C, E

A nurse is preparing to remove staples from a client's surgical incision. Which of the following actions should the nurse take? (Select all that apply) a. assure the client there will be no discomfort during the procedure b. lift the staple remover when squeezing the handle c. verify the rx for staple removal d. clean the surgical site e. examine in the incision

C, D, E

Select the 5 findings that can cause delayed wound healing a. potassium level b. prealbumin level c. hx of diabets d. hx of hyperlipidemia e. wound infection f. decreased pedal perfusion g. fasting blood glucose

C, E, F

A nurse is completing discharge instructions for a new mother and her 2 day old newborn. The mother asks, how will i know if my baby gets enough breast milk? Which of the following responses should the nurse make? a. your baby should have a wake cycle of 30-60 mins after each feeding b. your baby should we 6 to 8 diapers per day c. your baby should burp after each feeding d. your baby should sleep at least 6 hrs between feedings

b. your baby should we 6 to 8 diapers per day

A nurse on a med surg unit is caring for 4 clients who are 24-36 hr post op. Which of the following surgical procedures places the client at risk for DVT? a. myringotomy b. laproscopic appendectomy c. hip arthorplasty d. cataract extraction

c. hip arthorplasty

A nurse is reviewing the diagnostic test results of an older adult female client who is preop for a knee arthoplasty. The nurse should notfiy the surgeon of which of the following results? a. WBC count 20,000 b. hematocrit 40% c. creatinine 0.9 mg/dl d. postassium 3.8 mEq/l

a. WBC count 20,000

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take? a. apply an ice pack to the affected area b. offer a warm sitz bath c. provide a squeeze bottle of antiseptic solution d. place a hot pack to the perineum

a. apply an ice pack to the affected area

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? a. clear the resp tract b. dry the infant off and cover the head c. stimulate the infant to cry d. cut the umbilical cord

a. clear the resp tract

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? a. cold stress b. shivering c. basal metabolic rate reduction d. brown fat production

a. cold stress

A nurse is assessing a client who is post op and has anemia due to excess blood loss following surgery. Which of the following should the nurse expect? a. fatigue b. hypertension c. bradycardia d. diarrhea

a. fatigue

A nurse is preparing to administer an injection of Rh (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications? a. hydrops fetalis b. hypobilirubinemia c. bilary atresia d. transient clotting difficulties

a. hydrops fetalis

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes. The nurse should recognize which of the following newborn complications as the priority focus of care? a. hypoglycemia b. hypomagnesemia c. hyperbilirubinemia d. hypocalcemia

a. hypoglycemia

A nurse teaching a client who is preop how to do deep breathing exercises and cough effectively after surgery. Which of the following statement by the client indicates an understanding of the teaching? a. ill splint my incision with a pillow to cough b. ill ask for pain meds fater I do the exercises. c. ill use the incentive spirom when i can get out of bed d. ill breathe deeply and cough every 4 hrs

a. ill splint my incision with a pillow to cough

A nurse is assessing a newborn immediately following a scheduled c section. Which of the following assessment is the nurse priority? a. resp distress b. hypothermia c. accidental lacerations d. acrocynosis

a. resp distress

A nurse is preparing to administer vitamin K by IM to a newborn. The nurse should admin the medication into which of the following muscles? a. vastus lateralis b. ventrogluteal c. dorsogluteal d. deltoid

a. vastus lateralis

A nurse at an extended care facility is instructing a class of AP about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane? a. when the client moves, he should move the cane foward first b. the client should hold the cane on the weak side of his body c. the grip should be level with the client's waist d. the client should first move the strong leg, then the weak one

a. when the client moves, he should move the cane foward first

A nurse is assessing a newborn 1 hr after birth. Which of the following resp rates is within the expected reference range for a newborn? a. 22/min b. 48/min c. 100/min d. 110/min

b. 48/min

A nurse is caring for a client who is primigravada, at term, and having contractions but is stating that she is "not really sure if she is in labor or not". Which of the following shoudl the nurse recognize as a sign of true labor? a. rupture of the membranes b. changes in the cervix c. station of the presenting part d. patterns of contractions

b. changes in the cervix

A nurse is caring for a newborn and ausculatates an apical HR of 130/min. Which of the following actions should the nurse take? a. ask another nurse to verify the HR b. document this as an expected finding c. call the provider to further assess the newborn d. prepare the newborn for transport to the NICU

b. document this as an expected finding

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? a. administer vitamin K b. dry the skin c. administer eye prophylasxis d. place an identification bracelet

b. dry the skin

A nurse identifies a pressure ulcer after a client has a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? a. document what the nurse believes was the cause of the ulcer development b. include any relative statements the client made about the ulcer c. document in the client's medical record that she completed an incident report d. qustion the charge nurse about care deficits that might have contributed to the ucler's development

b. include any relative statements the client made about the ulcer

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? a. being phototherapy b. initiate early feeding c. suction excess mucous with a bulb d. prepare for an exchange blood transfusion

b. initiate early feeding

A nurse is caring for a client who is post op and is at risk for developing VTE. The nurse should instruct the client to avoid which of the followig unsafe actions? a. elevating her feet b. massaging her feet c. flexing her ankles d. ambulating soon after surgery

b. massaging her feet

A nurse is assessing a client 15 min after admin morphine sulfate 2mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication? a. sleepy, but arousing when her name is called b. resp rate 8/min c. pain level 6 d. spo2 94%

b. resp rate 8/min

A nurse is caring for a client who is post op following abd surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take? a. place the head of the client's bed in the flat position b. gently reinsert the bowel back into the client's wound c. apply moistened sterile gauze to the site d. positive the client on his left side

c. apply moistened sterile gauze to the site

A nurse is assessing a client 1 day post op following abd surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take? a. have the client lie flat in bed b. use sterile gauze to place gentle pressure on the exposed organs c. cover the area with saline soaked sterile dressings d. apply an abd binder

c. cover the area with saline soaked sterile dressings

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light brown serous drainage. Which of the following actions should the nurse perform first? a. check the client's vital signs b. assess the client's pain level c. cover the wound with a moist, sterile gauze dressing d. obtain a culture and sensitivity of the wound drainage

c. cover the wound with a moist, sterile gauze dressing

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? a. place the newborn on a warm surface b. preventing air drafts c. drying the newborn skin throughly d. maintaining ambient room temp

c. drying the newborn skin throughly

A nurse is caring for a newborn whose mother is positive for hep B surface antigen. Which of the following should the infant receieve? a. hep B immune globulin 1 week followed by hep B vaccine monthly for 6 months b. hep B vaccine monthly until the newborn tests neg for the hep B surface antigen c. hep B immune globulin and hep B vaccine within 12 hrs of birth d. hep B vaccine at 24 hr followed by hep B immune globulin every 12 hr for 3 days

c. hep B immune globulin and hep B vaccine within 12 hrs of birth

A nurse is teaching a client how to use an incentive spirometer. Which of the following statements should the nurse make? a. use the incentive spirometer once every 4 hrs b. hold your breath for 7 seconds when using the incentive spirom c. inhale through the incentive spirom 10 times with each use d. sit up at a 30 degree angle when using the incentive spirom

c. inhale through the incentive spirom 10 times with each use

A nurse is caring for a client who is 6 hr postpartum. The client is RH neg and her newborn is RH pos. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? a. it determine if kernicterus will occur in the newborn b. it detects RH neg antibodies in the newborns blood c. it detects RH pos antibiodies in the mothers blood d. it determines the presence of maternal antibodies in the newborns blood

c. it detects RH pos antibiodies in the mothers blood

A nurse caring for a client who is postop following an open reduction and internal fixation of a fracture femur. Which of the following actions is the most important for the nurse to complete in the post op period? a. medicate the client for pain b. instruct the client on use of crutches c. perform neurovascular checks of the extremities d. direct the client to perform exercies of the ankle and toes

c. perform neurovascular checks of the extremities

A nurse is assessing a client who is 48 hr post op following abd surgery. Which of the following findings should the nurse report to the provider? a. blood pressure 102/66 b. straw colored urine from indwelling urinary cath c. yellow green drainage on the surgical incision d. resp rate 18/min

c. yellow green drainage on the surgical incision

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? a. insert a NG tube b. admin antiemetic c. encourage use of incentive spiro d. auscultate bowel sounds

d. auscultate bowel sounds

A nurse is caring for a client 8 hr post op following a total knee replacement. Which of the following actions should the nurse take? a. place a pillow under the affected limb b. apply cool compress to the affected limb every 6 hr c. promote bed rest 5-7 days d. encourage increased fluid intake

d. encourage increased fluid intake

A nurse administering morphine 2mg IV very 2-4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects? a. diarrhea b. heartburn c. hiccups d. orthostatic hypotension

d. orthostatic hypotension

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amoutn of weight the newborn has lost since birth. Which of the following is a response the nurse should make? a. you might want to offer water supplements between feedings b. it is due to the newborn's loss of the influence of the maternal hormones c. the might be related to your baby having 3 stools a day d. the cause might be too short or infrequent feedings

d. the cause might be too short or infrequent feedings