SAUNDERS NP/ DATA COLLECTION

Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply.

"Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." "Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." "Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." "Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which early symptom?

Decreased force in the stream of urine

A client who has sustained an eye injury has been prescribed corticosteroid eye drops. The nurse should most carefully monitor for side effects of this medication if the client has which health problem listed on the medical record?

Diabetes mellitus

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding should the nurse expect to note documented in the infant's record regarding this condition?

Hip joint laxity

The nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse should expect to note which behavior in the client?

Slowed walking and talking

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function?

The transfer of digested food molecules from the GI tract into the bloodstream

The nurse in the delivery room is assisting with the delivery of a newborn. Which observations indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply.

The umbilical cord lengthens Changes in the shape of the uterus A trickle or gush of blood escapes from the introitus

The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that which is an early sign of rupture?

A decline in the level of consciousness

The nurse is monitoring a client receiving spironolactone by mouth daily. Which data would indicate to the nurse that the client is experiencing a side effect related to the medication?

A potassium level of 5.2 mEq/L

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition?

Bladder distention

During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." Which should the nurse check further?

Blood pressure changes and the presence of protein in the urine

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply.

Bright red vaginal bleeding and Soft, relaxed, nontender uterus

This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's signs/symptoms are indicative of which complication?

Compartment syndrome

The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of infection. Which sign/symptom is likely to present first?

Confusion

The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

Driving under the influence (DUI) conviction resulted in a 1-year suspended license

The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance? 1. Drowsiness, headache, and tachypnea 2. Tachypnea, dizziness, and paresthesias 3. Disorientation, hypotension, and dyspnea 4. Decreased respiratory rate and depth and cardiac irregularities

Drowsiness, headache, and tachypnea

The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which?

Lower the voice pitch and face the client when speaking.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.

Ileostomy output of 650 mL in 4 hours Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute

The nurse caring for a client diagnosed with acute pancreatitis and has a history of alcoholism is monitoring the client for complications. The nurse determines that which data collected is most likely indicative of paralytic ileus?

Inability to pass flatus

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?

Inspecting the abdomen

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which result?

Potassium 5.4 mEq/L

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.

Small parts are located on the left side of the uterus. Small parts are located on the right side of the uterus. A soft, irregular non-ballottable shape is located just above the symphysis pubis.

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which findings are early indications that the level of consciousness (LOC) is deteriorating? Select all that apply.

Drowsiness, less frequent speech, slight slurring of speech