Synthesis Extra Questions
A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5 mg/kg/dose subcutaneous every 12 hours. The client weighs 245 lbs. How many mg should the nurse administer per dose?
167 mg/dose
A nurse is preparing to administer Ringer's lactate by continuous IV infusion at 120 mL/hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
120 gtt/min
A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr?
125 mL/hr
A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide? -"I'll feed him today. Maybe tomorrow you can try it" -"Oh, this isn't difficult. You'll be fine doing this" -"You can learn to feed him; I wasn't comfortable the first time I fed a baby either" -"Feeding an infant can feel a little intimidating at first, but I'll stay and help you"
"Feeding an infant can feel a little intimidating at first, but I'll stay and help you" -The nurse, while recognizing and acknowledging the client's apprehension, offers assistance and a sense of presence, with the intention of boosting client confidence.
A nurse is providing teaching to a client who has gout and a new prescriptions for allopurinol. Which of the following statements indicates an understanding of the teaching? -"If I get a rash from this medication, I will take my usual antihistamine" -"I need to increase my fluid intake while taking this medication" -"I should take this medicine on an empty stomach" -"If I get a fever while taking this medication, I will take some aspirin"
"I need to increase my fluid intake while taking this medication" -Clients who have gout should increase their fluid intake to 2 to 3L per day to prevent toxicity of allopurinol and decrease uric acid levels.
A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching? -"I will take the antiemetic as soon as the chemotherapy infusion is complete" -"I will run my toothbrush in the dishwasher every month" -"I'll call my doctor if I notice an unusual menstrual bleeding" -"I will avoid crowds to keep from infecting others"
"I'll call my doctor if I notice an unusual menstrual bleeding" -Clients should be taught bleeding precautions and to report bruising or excessive bleeding.
A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? -"It determines if kernictertus will occur in the newborn" -"it detects Rh-negative antibodies in the newborn's blood" -"It detects Rh-positive antibodies in the mother's blood -"It determines the presences of maternal antibodies int he newborn's blood"
"It detects Rh-positive antibodies in the mother's blood -An indirect Coombs test determines the presence of Rh antibodies. If the client has Rh-negative blood, she does not produce Rh factor. Exposure to Rh positive blood, such as from an Rh factor positive fetus, could trigger the client to begin producing antibodies against Rh factor. These antibodies can cross the placenta and harm an Rh-positive fetus.
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have a natural childbirth. Which of the following responses should the nurse make? -"It sounds like you are feeling sad that things didn't go as planned" -"At least you know you ave a healthy baby" -"Maybe next time you can try to have a vaginal delivery" -"You can resume sexual relations sooner than if you had delivered vaginally"
"It sounds like you are feeling sad that things didn't go as planned" -This response uses the therapeutic communication technique of restating to encourage the client to continue to communicate her feelings.
A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate? -"You need to tell the voices to leave you alone" -"You need to understand that there are no voices" -"What are the voices telling you to do?" -"Why do you think you are hearing the voices?"
"What are the voices telling you to do?" -This statement recognizes the risk involved with a command hallucination and asks the client directly about the hallucination. This is a therapeutic approach to communicating with a client who is experiencing a hallucination.
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? -"You should place your nipple and some of the areola into her mouth" -"Babies know instinctively how much of the nipple to take into their mouth" -"You baby's mouth is rather small so she will only take part of the nipple" -"Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth"
"You should place your nipple and some of the areola into her mouth" -Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.
A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? -Lactated RInger's solution -0.9% sodium chloride -dextrose 5% in water -dextrose 5% in 0.45% sodium chloride
0.9% sodium chloride -The nurse should prime the tubing with 0.9% sodium chloride, as this is the only IV solution that does not hemolyze RBCs.
A nurse is preparing to administer amoxicillin 500 mg PO every 12 hours. The amount available is amoxicillin 250 mg/5 mL suspension. How many mL should the nurse administer?
10 mL
A nurse is caring for a client who is prescribed tetracycline 2 grams daily PO in four divided doses every 6 hours. Available is tetracycline 250 mg capsules. How many capsules should the nurse administer per dose?
2 capsules
A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance? -0.5 mL/kg/hr -2 mL/kg/hr -7.5 mL/kg/hr -15 mL/kg/hr
2 mL/kg/hr -The expected urinary output for infants up to the age of 1 year is 2 mL/kg/hr. An infant who is not dehydrated should produce this amount of urine.
A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? -4-0-1-2-2 -3-0-2-0-2 -2-0-0-2-0 -4-2-0-2-2
4-0-1-2-2 -This response correctly describes the client's current status: pregnant currently and had 3 prior pregnancies (G); no term births (T); one pregnancy resulted in the preterm birth (P) of twins; two pregnancies ended in abortion (A); and she has two living children (L).
a client is prescribed 1 g potassium phosphate IV to be infused continuously over 6 hours. Available is 1 g potassium phosphate in 250 mL dextrose 5% water (D5W). The nurse should set the IV pump to run at how many mL/hr?
42 mL/hr
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that preceded labor? -decreased vaginal discharge -a surge of energy -urinary retention -weight gain of 0.5 to 1.5 kg
a surge of energy -Prior to the onset of labor, the pregnant client experiences a surge of energy.
A nurse on a telemetry unites caring or a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? -administer another nitroglycerin tablet -initiate a peripheral IV -call the Rapid Response Team -obtain an ECG
administer another nitroglycerin tablet -Administration guidelines for sublingual nitroglycerin indicate that it is appropriate to administer another tablet 5 min after the first one if the client is still reporting pain.
A nurse in a clinic is reviewing the medical records of a group of clients who are regnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients? -a client who has mitral valve prolapse -a client who has been exposed to AIDS -all of the clients -a client who has a history of preterm labor
all of the clients -MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman.
A nurse is caring for a client 3 days after admission for treatment of depression. The client leave her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take? -ask the client if she has a plan to commit suicide -recognize the attempt at manipulation and escort the client back to her activity -assist the client to her room and allow her to rest before resuming activity -notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone
ask the client if she has a plan to commit suicide -The nurse should take seriously all statements regarding suicide. Asking the client if she has a suicide plan is a specific question that the nurse should include when assessing a client who has possible suicidal ideation.
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? -encourage the client to perform Kegel exercises -encourage the client to move to the left lateral position -ask the client to rate her pain -assist the client to the bathroom to void
assist the client to the bathroom to void -A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? -prepare for a cesarean birth -assist the client to an upright position -prepare for an immediate vaginal delivery -assist the client to turn on her side
assist the client to turn on her side -Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.
A nurse is caring for a child who has tine pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names? -shingles -athlete's foot -fever blister -valley fever
athlete's foot -Athlete's foot is the common name for tinea pedis.
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings conform to the nurse that the client is in labor? -cervical dilation -report of pain above the umbilicus -brownish vaginal discharge -amniotic fluid in the vaginal vault
cervical dilation -Cervical dilation and effacement are indications of true labor.
A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care? -rotate staff assignments for this client -use touch to calm the client during periods of anxiety -check the client's mouth after the client takes medication -assign an assistive personnel to feed the client at mealtimes
check the client's mouth after the client takes medication -This action is appropriate for clients who have paranoid schizophrenia as it helps assure that the client is swallowing medication.
A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? -position the newborn to promote extension of muscles -use fingertips when calming the newborn -cluster the newborn's care activities -keep the newborn in a well-lit nursery
cluster the newborn's care activities -By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development.
A nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? -command hallucination -gustatory hallucination -cognitive distortion -somatic delusion
command hallucination -This finding is correctly identified as a command hallucination.
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? -assist the client into a comfortable position -observe the perineum for signs of crowing -have the client pant during the next contraction -help the client to the bathroom to void
have the client pant during the next contraction -Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication fro m the epidural block? -vomiting -tachycardia -respiratory depression -hypotension
hypotension -Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.
A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out which yelling, "You are all making fun of me." Which of the following behaviors is the client displaying? -grandeur -flight of ideas -erotomania -ideas of reference
ideas of reference -Ideas of reference occur when a client believes that conversations of others always concern him and that others are ridiculing him.
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included int he plan of care? -allow manipulation so as to not raise the client's anxiety -avoid discussing past behaviors with the client -institute consequences for manipulative behavior -bargain with the client to discourage manipulative behavior
institute consequences for manipulative behavior -The nurse should work with the client to develop a behavior plan that includes specific consequences for manipulative behavior.
A nurse is caring for. newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? -perform a sharp hand clap near the infant -hold the newborn vertically allowing one foot to touch the table surface -place a finger at the base of the newborn's toes -turn the newborn's head quickly to one side
perform a sharp hand clap near the infant -To elicit the Moro reflex, the nurse performs a sharp hand clap near the newborn and observes symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger to form a C, and then a return to a relaxed flexion position.
A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide? -wash the affected area with soap and water before applying cream -increase intake of fluids while using this medication -the medication might cause temporary blurred vision -apply the cream to large areas around the infection
wash the affected area with soap and water before applying cream -The client should wash the affected area with soap and water and dry it thoroughly before applying the cream.
A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? -sedation -increased appetite -white coating in the mouth -dry oral mucous membranes
white coating in the mouth -Fluticasone / salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.
A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching? -"I'll dial 911 if I still have pain after taking 3 nitroglycerin tablets 5 minutes apart" -"I'll dial 911 if I still have pain after taking 4 nitroglycerin tablets over a 20 minute period" -"I'll dial 911 when I have pain and then take the nitroglycerin tablets" -"I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting"
"I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting" -If 1 nitroglycerin tablet does not relieve the client's pain, he should access emergency services and then take 2 more tablets at 5-min intervals if he still has pain.
A nurse is evaluating teaching o a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching? -"I'll rinse my mouth after taking this medication" -"I'll take this medication when I get an asthma attack" -"I'll take this medication once a day in the evening" -"I'll use a spacer device when I inhale this medication"
"I'll take this medication once a day in the evening" -Montelukast, a leukotriene modifier, is used to prevent asthma exacerbations. The client should take it on a daily basis once a day in the evening.
A nurse is providing discharge teaching to a client who has. new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?-"It's okay to have a couple glasses of wine with dinner each evening" -"I'll be sure to eat more foods with vitamin K -"I'll take aspirin for my headaches" -"I'll use my electric razor for shaving"
"I'll use my electric razor for shaving" -Because this medication prolongs clotting times, the client should avoid situations that put him at high risk for bleeding, such as shaving with a straight razor or a razor blade.
A nurse in a providers office is caring for a client who is at 36 weeks of gestation and is scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? -"This will determine if there is more than one fetus" -"It is useful for estimating fetal age" -"It assists in identifying the location of the placenta and fetus" -"This is a screening tool for spina bifida"
"It assists in identifying the location of the placenta and fetus" -Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.
A nurse is caring for a client who is 16 hours postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide? -"Most newborn mothers feel somewhat anxious about things like this" -"There's nothing for you to worry about. Newborns often breathe this way" -"Why do you think there is something wrong with that?" -"Let's sit here together and observe your baby while you feed him"
"Let's sit here together and observe your baby while you feed him" -With this response, the nurse is using the therapeutic communication techniques of focusing and physical attending.
A nurse is reading the medical record for a client who has schizophrenia which indicates that the client exhibits depersonalization. Which of the following statements by the client confirms that she is experiencing depersonalization? -"I have broken off all my past relationships because my friends and family are trying to kill me" -"I hear voices telling me that I have been bad" -"My hands and feet are much smaller than they used to be" -"Everything in this room has changed and I don't recognize it anymore"
"My hands and feet are much smaller than they used to be" -The client who experiences depersonalization might feel that parts of her body belong to someone else or are different in some way. Depersonalization is experienced as a loss of personal identity.
A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide? -"Do not have vaginal intercourse until later your next period" -"Stop taking the pills and switch to a different contraceptive method" -"Take the missed dose now, then continue the medication as ordered" -"Take a home pregnancy test"
"Take the missed dose now, then continue the medication as ordered" -The nurse should tell the client to take the missed dose immediately, then continue with the pack as ordered. The nurse should also tell the client to use an additional form of contraception for 7 days.
A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention? -"It sounds frightening to feel like both God and the devil at the same time" -"I don't understand. Can you tell me what that means?" -"Are you saying that you are both good and bad?" -"There is no gate for me to open"
"There is no gate for me to open" -This reply can be viewed as argumentative by the client and is nontherapeutic for communicating with a client who is experiencing a delusion.
A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make? -"Take only one dose of nitroglycerin to reduce the risk of getting a headache" -"There's nothing that can be done to relieve the headaches that nitroglycerin causes" -"Try taking a mild analgesic to relieve the headache" -"We will ask the provider to prescribe a different medication for you"
"Try taking a mild analgesic to relieve the headache" -Headache is a common side effect of nitroglycerin. The nurse should suggest conservative measures, such as taking aspirin, acetaminophen, or some other mild analgesic, to manage the headache. Generally, headaches that are a side effect of nitroglycerin are transient.
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate? -withholding the medication if the heart rate is above 100/min -instructing the client to eat foods that are low in potassium -measuring apical pulse rate for 30 seconds before administration -evaluating the client for nausea, vomiting, and anorexia
evaluating the client for nausea, vomiting, and anorexia -Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity.
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? -prior physical health followed by the need for two surgeries within the last three months -obsession over a fictitious defect in physical appearance -sudden unexplained loss of peripheral sensation -constant worry about the undiagnosed presence of an illness
constant worry about the undiagnosed presence of an illness -Clients who have illness anxiety disorder constantly worry about the presence of a serious illness even though medical tests do not support this concern.
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions? -denial -displacement -projection -undoing
denial -Denial is a defensive coping mechanism that protects the client from increasing anxiety levels. The client consciously disowns intolerable thoughts and ideas. It is a common response of victims of violent crimes.
A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider? -blurred vision -palpitations -constipation -depression
depression -Montelukast can cause neuropsychiatric effects such as depression, behavior changes, hallucinations, and suicide ideation. The nurse should instruct the client to report such adverse effects. A change in medication might be prescribed.
A nurse is providing teaching to a client who has hypertension and a new prescription for captopril. Which of the following instructions should the nurse provide? -do not use salt substitute while taking this medication -take the medication with food -count you pulse rate before taking the medication -expect to gain weight while taking this medication
do not use salt substitute while taking this medication -Captopril, an ACE inhibitor, can cause hyperkalemia due to potassium retention by the kidney. The client should avoid salt substitutes, as most of them are high in potassium.
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? -ask another nurse to verify the heart rate -document this as an expected finding -call the provider to further assess the newborn -prepare the newborn for transport to the NICU
document this as an expected finding -The expected reference range for an apical pulse in a newborn who is awake is 120 to 160/min. The nurse should document this as an expected finding.
A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include? -take an antiemetic 1 hour following administration -drink 2 to 3 L of water per day -take the medication with an NSAID -rinse mouth 2 times per day with an alcohol based mouthwash
drink 2 to 3 L of water per day -Methotrexate can cause renal toxicity. The client should drink 2 to 3 L of water per day to promote excretion of the medication.
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? -flushing -dyspnea -bradycardia -vomiting
dyspnea -Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention.
A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? -take aspirin if headaches develop -eat foods that contain plenty of potassium -expect some swelling in the hands and feet -take the medication at bedtime
eat foods that contain plenty of potassium -Furosemide, a high-ceiling (loop) diuretic, can cause potassium loss. The client should add potassium-rich foods to his diet, such as nuts, dried fruits, bananas, and citrus fruits.
A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis? -aspirin PO -enoxaparin subcutaneous -heparin infusion -warfarin PO
enoxaparin subcutaneous -Enoxaparin is a low molecular heparin that inhibits thrombus and clot formation. Preventive doses of enoxaparin are low and the client does not require monitoring of prothrombin time or activated partial thromboplastin time, making it the preferred treatment for DVT prophylaxis following orthopedic surgery.
A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching? -have the child remain at the table after meals to increase food intake -add fruit juice to the child's diet to increase vitamin intake -emphasize the quantity, rather than the quality, of food consumed -expect that food consumption might not decrease significantly
expect that food consumption might not decrease significantly -Food consumption varies and most preschool-age children consume an adequate quantity of food despite their fads and preferences.
A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? -expressions of excitement -lack of appetite -focus on the daily unit and its members -eagerness to learn newborn care skills
expressions of excitement -Expressing excitement and being talkative are characteristic of this phase.
A nurse is caring for a client who is taking digoxin for heart failure and develops indications of severe digoxin toxicity. Which of the following medications should the nurse prepare to administer? -fab antibody fragments -flumazenil -acetylcystine -naloxone
fab antibody fragments -Fab antibody fragments, also called digoxin immune Fab, bind to digoxin and block its action. The nurse should prepare to administer this antidote IV to clients who have severe digoxin toxicity.
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? -fetal attitude is in general fixation -fetal lie is longitudinal -maternal pelvis is gynecoid -fetal position is persistent occiput posterior
fetal position is persistent occiput posterior -The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief.
A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect? -fundus soft, 1 cm to the right of the umbilicus -fundus firm, at the level of the umbilicus -fundus present, to the left of the umbilicus -fundus soft, 2 cm above the umbilicus
fundus firm, at the level of the umbilicus -Within 12 hours after birth, the fundal tone is expected to be firm and the location is typically palpated midline and at the level of the umbilicus.
A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? -monitor the client closely to prevent self-mutilation -sets limits to prevent exploitation of other clients -discourage flamboyant or seductive behaviors -give positive feedback when client is assertive with staff or clients
give positive feedback when client is assertive with staff or clients -The client who has dependent personality disorder has great difficulty demonstrating assertive behavior and commonly relies on others to make decisions. The nurse should encourage the client to be more assertive and independent.
A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication? -milk -orange juice -coffee -grapefruit juice
grapefruit juice -Grapefruit juice increases blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of medication can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness.
A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take? -place the client in seclusion if visual hallucination are present -limit the number of questions asked during assessments -use frequent touch to provide client support -directly tell the client that delusions are not real
limit the number of questions asked during assessments -Minimizing the number of questions is appropriate since a client who has acute schizophrenia has difficulty concentrating on information and answering assessment questions. The nurse should plan to use other sources of client information, such as medical records, family members, or reports from other interprofessional sources.
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? -administer prescribed analgesic medication -encourage the client to rest between contractions -massage the client's back -turn the client into her left side
massage the client's back -The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client's back focuses on neuromuscular and cognitive changes.
A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? -offer the client a light snack -measure the client's blood pressure -measure the client's apical pulse -weigh the client
measure the client's apical pulse -Digoxin decreases the heart rate, so the nurse should count the apical pulse for at least 1 min before administering. The nurse should hold the medication and notify the provider if the client's heart rate is below 60/min or if a change in heart rhythm is detected.
A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? -abruptio placentae -placenta previa -precipitous labor -threatened abortion
placenta previa -Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.
A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn? -acrocyanosis of hands and feet -anterior fontanel soft and level -plantar creases cover 2/3 of sole -vernix caseosa in inguinal creases
plantar creases cover 2/3 of sole -Observing the presence of creases on the plantar surface is one of the components of a gestational age assessment.
A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect? -red currant jelly stools -distended neck veins -projectile vomiting -rigid abdomen
projectile vomiting -Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine. The narrowing does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.
A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose? -iron -glucagon -protamine -vitamin K
protamine -Protamine reverses the effects of heparin and is used in the event of an overdose.
A nurse is caring for a client who is 1 day postpartum and is taking a sit bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform? -bladder distention -pulse rate -respiratory rate -color of loch
pulse rate -A sitz bath causes vasodilation; therefore, the nurse should monitor the client's pulse rate. Orthostatic hypotension can occur upon standing causing the client to feel faint.
A nurse in a prenatal clinic is caring for a client. using Leopold maneuvers, the nurse palpated a round, firm, moveable part in the funds of the uterus an a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? -left lower -right lower -left upper -right upper
right upper -Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant.
A nurse is teaching a client about diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication? -sedation -constipation -hypertension -bradycardia
sedation -Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia.
A nurse is providing teaching to a client who has a new prescription for levothyroxine for hypothyroidism. The nurse should instruct the client to avoid which of the following herbal supplements? -saw palmetto -cranberry -soy -garlic
soy -The nurse should instruct the client to avoid soy because soy can reduce the effectiveness of the levothyroxine.
A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? -reduces inflammation -suppresses the urge to cough -dries mucous membranes -stimulates secretions
stimulates secretions -Expectorants act by increasing secretions to improve a cough's productivity.
A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an expected finding? -death of client's father two months ago -experiences frequent facial tics -suspended from school several times in the past year -adheres strictly to routines
suspended from school several times in the past year -Conduct disorder is an impulse-control disorder which includes a long-term pattern of violating the rights of others and performing violent or hostile acts.
A nurse is providing teaching to a client who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse include? -take 1 capsule at the onset go anginas pain -stop taking the medication if the side effects are troublesome -take the medication with meals -swallow the capsules whole
swallow the capsules whole -The client should swallow the capsules whole and not chew or crush them or place them under the tongue.
A nurse on the labor and delivery unit is caring for a client following. vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? -the presenting part is 1 cm above the ischial spines -the presenting part is 1 cm below the ischial spines -the cervix is 1 cm dilated -the cervix is effaced 1 cm
the presenting part is 1 cm above the ischial spines -Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.
