Kaplan QT 1
Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best?
"SHARE will provide you with this opportunity." SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage
During the mother's fourth stage of labor, the nurse palpates the client's fundus in which location?
At the umbilicus uterus is normally contracted and palpable at the umbilicus
The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occurring?
Extrapyramidal adverse effects resulting from this medication. adverse effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing)
The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia?
Facial swelling and proteinuria. also includes hypertension
The nurse knows that according to Erikson's stages of psychosocial development, which developmental stage best represent a 50-year-old client?
Generativity versus stagnation. 45-64 years
Which action is the best way for the nurse to assess the fluid balance of an elderly client?
Maintain an accurate intake and output.
The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation?
The health care provider is able to examine the urinary tract by x-ray. x-rays of entire urinary tract taken, evaluates kidney function
The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis?
The leg appears to be shortened and is adducted and externally rotated.
Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit?
"The client constantly calls for nurses and cries uncontrollably." gives an objective description of the client's behavior and affect
The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate?
"You are less likely to awaken during the night with heartburn if the stomach is empty." full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn
The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding?
500 milk production requires an increase of 500 calories per day
The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group?
Associative play Solitary play- Infant Parallel play- Toddler
The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication?
Check the client's heart rate verapamil is indicated for the treatment of supraventricular tachycardia, so the client's heart rate should be checked prior to administration
The nurse knows that cortisol is responsible for which action?
Converting proteins and fat into glucose action of cortisol; is also an anti-inflammatory agent
The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion?
ROM assists the elderly to carry out activities of daily living (ADLs). emphasis should be on ROMs that support ADLs
The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason?
The renal threshold for glucose is elevated in the elderly. the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels
At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement?
The results will inform us of the baby's size. ultrasound detects the size, growth patterns, and gestational age
The nurse performs the Rinne test on a client. Which is an accurate statement of how the first part of this test is performed?
The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard. client should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction
The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication?
Corneal abrasion. client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye
The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to intravenous drug use?
Narcotics Most often used IV
Which is most important for the rehabilitation nurse to assess during a new client's admission?
The client's personal goals for rehabilitation. it is important for the nurse to understand what the client expects from the rehabilitation program for future success
The nurse cares for a client receiving docusate 100 mg through a gastric tube. The solution contains 150 mg/15 mL. The nurse should administer how many mLs of the solution to the client?
150 mg/15 mL = 100 mg/X X = 10 mL
The nurse cares for the client receiving D5 0.45% NS 1,000 mL to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/mL. At what rate does the nurse set the IV to drip?
42 gtts/min
The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior?
Abusive language is one of the behaviors symptomatic of the client's illness.
The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents?
Adequate protein, low sodium intake. if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted
Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information?
Allergy to shellfish allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure
The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics?
An infant with a small head circumference, low birth weight, and undeveloped cheekbones.
In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior?
Anger
The nurse identifies which finding has the greatest impact on the elderly client's ability to complete activities of daily living (ADLs)?
Apraxia apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly
The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process?
Being NPO inhibits normal blood glucose control temporary control by insulin is needed due to inability to control diabetes mellitus by diet and oral agents, surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids
The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe?
Cellulitis. most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus
The client is evaluated for infertility, and the health care provider prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best?
Clomiphene citrate induces ovulation by changing hormonal effects on the ovary. clomiphene citrate induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum
The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe?
Delicate Features appear younger than chronological age
The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom?
Delusions of persecution client has delusions of persecution; delusion is a strongly held belief that is not validated by reality; the idea that a family member is trying to steal property is a belief not validated by reality
The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, which action does the nurse take first?
Determines the client's comprehension of the medication administration. assessment; intellectually delayed client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdose and underdose
The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes which nursing diagnosis?
Difficulty coping client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is inability to cope
The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process?
Elderly adults engage in less activity and have decreased GI muscle tone. reduced gastrointestinal motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, adverse effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat
The nurse recognizes which symptoms are early signs of lithium toxicity?
Fine motor tremors. Nausea and vomiting and Diarrhea Given for Bipolar disorder
The health care provider orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms?
Fluid retention and dizziness. NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; adverse effects include headache, dizziness, gastrointestinal distress, pruritus, and rash
Which type of foods does the nurse encourage for the client diagnosed with hypoparathyroidism?
Foods high in calcium. diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance diet should be low in phosphorus; hypoparathyroidism is decreased secretion of parathyroid hormone; indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm calcium and phosphorus are inversely proportional
The health care provider orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for which adverse effects?
Hypotension and respiratory depression. narcotic analgesic used for moderate to severe pain, monitor vital signs frequently
The nurse provides care for a client with a tracheostomy. Which is the priority nursing diagnosis for this client?
Inadequate airway clearance. inadequate airway clearance is the top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions
The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker?
Increases the cardiac output. Acts to regulate cardiac rhythm
A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure?
Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn. insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion
The 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms?
Inspiratory stridor and restlessness. this condition is characterized by edema and inflammation of upper airways
The nurse cares for the prenatal client at 8 weeks gestation with a positive VDRL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information?
Instruct the client about the importance of taking all of the medication. physical, vitally important to complete all the medication
The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV?
Maintain fluid balance. loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement
The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action?
Make the infant NPO for 3 hours. prior to the procedure
The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler?
Milk milk contains calcium; calcium binds to lead and inhibits its absorption
The nurse cautions the client with hypothyroidism to avoid which implementation?
Narcotic sedative client is very sensitive to narcotics, barbiturates, and anesthetics
The parent of a child with chickenpox asks the clinic nurse why the child will not come down with chickenpox again if exposed to the virus at school at a later date. Which explanation does the nurse give?
Natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus. antigen enters the body without human assistance; body responds by actively making antibodies
The adult client is preparing for a plasma cholesterol screening. Which instruction does the nurse give to the client?
Only take sips of water for 12 hours before the test. to achieve accurate results
The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action?
Perform good hand washing good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients
A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication?
Pressure on the ocular suture line. sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line
A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors?
Projection and displacement. projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object)
The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents?
Repeat the application of the cream rinse in 7 days if nits are still present. may be repeated 7 days after first application
The nurse cares for the client receiving a blood transfusion for approximately 30 minutes. Which symptom indicates a severe allergic reaction is occurring?
Respiratory wheezing allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema
Which observation suggests to the nurse the client has developed an Addisonian crisis?
Restlessness and rapid, weak pulse. may be signs of shock related to an Addisonian crisis
The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give?
Rice cereal is usually the first solid food and is started around 4 to 5 months infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast-fed infants may be started on solids even later
Which information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis?
Right upper abdominal pain.
The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings?
Sitting with support Playing peek-a-boo. Rolling from back to abdomen.
The nurse cares for clients in the outpatient clinic. In which order will the nurse return the messages?
Strategy: Identify any normal behaviors. Identify the least stable infant to see first. 1) first: bulging fontanelle may indicate increased intracranial pressure and is most serious 2) second: circumcision should have yellowish exudate at this time, but swelling is not normal and may interfere with urination 3) third: umbilical cord should be dry and hard; draining indicates a possible infection and needs to be assessed 4) last: describes the Moro Reflex and is normal
The nurse cares for the client with ataxia. Which action is most important?
Supervise ambulation client's coordination is poor;
The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes?
Surface of the tongue cephalosporin, long-term use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended oral thrush
The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed?
The LPN/LVN positions the client left Sims' position. allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution
The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate?
The bowel preparation is incomplete. colon should not have remaining soft stool
The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for clients for 3 years. The RN cares for which client?
The client ordered to receive two units of packed cells. requires the assessment and teaching skills of the RN
The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement?
The client's decreased vision is caused by gradual destruction and degeneration of the retina. gradual destruction occurs because of deterioration of the retinal vessels
The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information?
The colostomy needs to be irrigated at the same time every day. to assist in establishing a normal pattern of elimination
The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made?
The fluid in the water-seal chamber does not fluctuate with respirations. indicates no more air leaking into the pleural space
The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. Which best describes the nurse's liability?
There is no order for a second dose of medication; the nurse is liable.
The client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor?
To monitor the oxygen status of the fetus during labor. goal is early detection of mild fetal hypoxia
Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?
Tremors. Elevated temperature. Nocturnal leg cramps symptoms of withdrawal from alcohol.
The health care provider orders mannitol for the client with a closed head injury. Which response does the nurse recognize as desired to this medication?
Urinary output increases to 175 mL/hour. mannitol is an osmotic diuretic; increases urinary output and decreases intracranial pressure
The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best?
hemophilia is a sex-linked disorder "The mother transmits the gene to her son."