PassPoint

The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?

"Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."

A client is admitted to the hospital for a suspected eating disorder. Which statement indicates that the client may be suffering from anorexia nervosa?

"I'm a perfectionist, and I work hard to get As."

The nurse is recording the intake and output for a client with the following: D5NSS 1,000 mL; urine 450 mL; emesis 125 mL; Jackson Pratt drain #1 35 mL; Jackson Pratt drain #2 32 mL; and Jackson Pratt drain #3 12 mL. How many milliliters should the nurse document as the client's output? Record your answer using a whole number.

654

Which client is at greatest risk for developing acute renal failure?

A client with diabetes who has a heart catheterization

While obtaining a client's medication history, the nurse learns that the client takes ranitidine, as prescribed, to treat a peptic ulcer. The nurse continues gathering medication history data to assess for potential drug interactions. The nurse should instruct the client to avoid taking a drug from which class with ranitidine?

Antacids

Which intervention would be appropriate for an infant after cardiac catheterization?

Apply pressure if oozing or bleeding is noted

A nurse caring for a client following a cholecystectomy observes distension over the suprapubic area. The client states he or she has not voided for 10 hours. What is the appropriate action by the nurse?

Assist the client to sit up to try to void.

A nurse caring for a client who reports sexual dysfunction knows that several conditions can cause sexual dysfunction in men. Which condition is one of the most common causes?

Diabetes Mellitus

A 55-year-old female client who's in cardiac rehabilitation tells a nurse that she can't make love to her husband because she often feels excessively fatigued and has a sense of doom. Which nursing intervention is most appropriate?

Encourage her to verbalize her feelings while a physical examination is performed.

A nurse is caring for a client who's receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Ensure adequate hydration before the anesthetic is administered.

A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?

Explain that these are expected problems for the latter stages of pregnancy.

A nurse is caring for a client with lower back pain who's scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position?

Head of the bed elevated 45 degrees

A 50-year-old male client who is taking antihypertensive medication tells the nurse who's monitoring his blood pressure that he can't have sexual intercourse with his wife anymore. Which problem is most likely the cause?

His blood pressure medication

A neonate just born 8 weeks' preterm has no spontaneous respirations but is successfully resuscitated. Within several hours, he develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. He's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing intervention should be included in the neonate's care plan to prevent retinopathy of prematurity?

Monitor partial pressure of oxygen (PaO2) levels.

When caring for a client who has had a cesarean section, which of the following actions is appropriate?

Monitoring pain status and providing necessary relief

Which of the following immunizations should an adolescent, age 12, receive as a component of preventative care?

Tetanus and diphtheria toxoids

A nurse has a four-patient assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology?

The client with diabetes insipidus.

Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which concerns?

Headache, blurred vision, and facial and extremity swelling

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply?

Moist sterile saline gauze

The nurse is planning care for a client who is argumentative and demanding, calling the nurse frequently. What is the nurse's best intervention?

Include the client in the decision-making process.

When caring for a client with a diagnosis of diabetes insipidus, which nursing intervention should be the nurse's priority?

Maintain adequate fluid intake

A nurse is assigned the care of six clients and has the aid of a nursing assistant. Which task is appropriate for the nurse to delegate to the nursing assistant?

Measuring and recording nasogastric tube output