Care Exam 5 Practice Questions (Final)

a. "Your provider might prescribe anticholinergic medications." b. "You should limit fluids in the evening." c. "You should restrict your intake of caffeine."

6. A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. "Your provider might prescribe anticholinergic medications." b. "You should limit fluids in the evening." c. "You should restrict your intake of caffeine." d. "You might require intermittent urinary catheterization."

a. rear-facing

A 15-month-old child weighs 26 pounds and is 35 inches. What type of car seat below is considered the SAFEST for this child to use while riding in a motor vehicle? a. rear-facing b. forward-facing c. booster seat d. seat belt

b. preeclampisa

A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension. What risk factor below found in the patient's health history places her at risk for abruptio placentae? a. childhood polio b. preeclampisa c. prior c-section d. her age

d. "Tell me what you mean when you say you can't go on any longer."

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? a. "Are you thinking of suicide?" b. "You've been doing a good job raising your children. You can do it!" c. "Is there someone who can help you during the evenings and weekends?" d. "Tell me what you mean when you say you can't go on any longer."

c. "First, I will pee a small amount of urine in the toilet and then collect the rest in the cup."

A 36 year old female, who is 29 weeks pregnant, reports she is experiencing burning when voiding. The physician orders a urinalysis. Which statement by the patient demonstrates she understands how to collect the specimen? a. "I'll hold the cup firmly against the urethra while collecting the sample." b. "I will cleanse back to front with the antiseptic wipe before peeing in the cup." c. "First, I will pee a small amount of urine in the toilet and then collect the rest in the cup." d. "I will be sure to drink a lot of fluids to keep the urine diluted before peeing into the cup."

d. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

A 36-year-old male client is about to be discharged from the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse's instructions about measures to prevent constipation? a. Discouraging the client from eating large amounts of roughage-containing foods in the diet. b. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination. c. Instructing the client to establish a bowel evacuation schedule that changes every day. d. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

b. Changing positions and walking does not decrease discomfort. c. The contractions are regular. d. The cervix is 90% effaced and dilated to 4 cm.

A 39 week pregnant woman arrives to labor triage. The patient's prenatal history includes G3, P2. What signs and symptoms below indicate the patient is experiencing true labor? (Select all that apply) a. The patient states the contractions are located above the umbilicus. b. Changing positions and walking does not decrease discomfort. c. The contractions are regular. d. The cervix is 90% effaced and dilated to 4 cm.

b. Tobacco use

A 50-year-old woman who weighs 95 kg has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. Which is the most important risk factor for peripheral artery disease (PAD) to address in the nursing plan of care? a. Salt intake b. Tobacco use c. Excess weight d. Sedentary lifestyle

a. cluster headaches

A 50-yr-old man reports recurring headaches. He describes them as sharp, stabbing, and around his left eye. He says his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect he has which of the following? a. cluster headaches b. tension headaches c. migraine headaches d. medication overuse headaches

d. Readiness to learn

A 55-year-old adult male has been in the hospital over a week following surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? a. Motivation to learn b. Developmental stage c. Stage of grief d. Readiness to learn

c. Role-playing

A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: a. Demonstration b. Preparatory instruction c. Role-playing d. Group instruction with other family caregivers

c. Loss of recent and long-term memory

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find which of the following? a. Excessive nighttime sleepiness b. Difficulty eating and swallowing c. Loss of recent and long-term memory d. Fluctuating ability to perform simple tasks

a. The patient was oriented and alert when admitted **delirium has a sudden onset

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted b. The patient's speech is fragmented and incoherent c. The patient is oriented to person but disoriented to place and time d. The patient has a history of increasing confusion over several years.

a. "Collect a urinalysis"

A 76 year old female is admitted due to a recent fall. The patient is confused and agitated. The family members report that this is not normal behavior for the patient. Based on the information you have gathered about the patient, which physician's order takes priority? a. "Collect a urinalysis" b. "Restrict their fluids " c. "Insert a Foley Catheter" d. "Keep patient NPO"

c. ureters d. kidneys **A and B are lower UTIs

A UTI in which part of the body indicates an upper urinary tract infection? (Select all that apply) a. bladder b. urethra c. ureters d. kidneys

a. stress

A bladder sling is a care management strategy that is most effectively used for which type of incontinence? a. stress b. overflow c. urge d. functional

b. no one

A charge nurse has access to the facility's electronic client records. Is it appropriate for the charge nurse to share her personal password with whom? a. the nurse manager b. no one c. a nursing student who is completing preceptorship d. the unit clerk

d. intonation

A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? a. personal space b. posture c. eye contact d. intonation

c. it is goal-directed d. behavioral change is encouraged e. a termination date is established

A charge nurse is discussing the characteristics of a nurse-patient relationship with a new nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply) a. the needs of both participants are met b. an emotional commitment exists between both participants c. it is goal-directed d. behavioral change is encouraged e. a termination date is established

b. Denial c. Bargaining d. Anger e. Depression

A charge nurse is reviewing Kubler-Ross' 5 stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply) a. Disequilibrium b. Denial c. Bargaining d. Anger e. Depression

a. "I need to talk to you about unit expectations regarding delegating and completing tasks"

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on the next shift report that the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? a. "I need to talk to you about unit expectations regarding delegating and completing tasks" b. "Several staff members have commented that you don't do your fair share of the work" c. "If you don't do your share of the work, I will have to inform the nurse manager" d. "You have been very inconsiderate of others by not completing your share of the work"

d. "I care about you and I am concerned that you feel so sad"

A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? a. "Of course people care. Your family comes to visit every day" b. Why do you feel that way?" c. "Tell me who you think doesn't care about you" d. "I care about you and I am concerned that you feel so sad"

d. True contractions **true contractions do not go away with hydration and walking

A client calls a provider's office and reports having contractions for 2 hours that increased with activity and did not decrease with rest and hydration. The client denies leaking of fluids, but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? a. Braxton Hicks contractions b. Rupture of membranes c. Fetal descent d. True contractions

d. Take prescribed antihypertensive medication.

A client diagnosed with chronic hypertension earlier in the year arrives to the clinic with a blood pressure of 192/98 mm Hg. Which is the priority teaching the nurse provides for this client based on the current data? a. Exercising 30 minutes a day. b. Limit sodium and potassium intake. c. Daily weights on the same scale. d. Take prescribed antihypertensive medication.

a. inflammation of the kidney

A client diagnosed with pyelonephritis asks the nurse "What is the disease?" The nurse's best response "Pyelonephritis is an: a. inflammation of the kidney b. inflammation of the prostate gland. c. inflammation of the urethra. d. inflammation of the bladder."

b. Caregiver role strain

A client expresses to the nurse that she constantly feels irritated and loses her temper. During the course of the interview, the nurse finds that the client takes care of her mother who was confined to bed following a stroke. The client struggles to balance caring for her family and her mother. Which nursing diagnosis would the nurse most likely identify for this client? a. Compromised family adjustment b. Caregiver role strain c. Ineffective coping d. Anxiety

c. Sleeps with a pillow under the residual limb **could cause hip flexion contractures

A client had a right below-the-knee amputation four weeks ago. Which finding should be of concern to the home health nurse? a. Cleans the residual limb while bathing b. Takes gabapentin for phantom limb pain c. Sleeps with a pillow under the residual limb d. Wraps the residual limb with an elastic bandage.

d. Stage 4

A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. Which stage should the nurse document this ulcer to​ be? a. Stage 3 b. Stage 2 c. Stage 1 d. Stage 4

d. Sensory reception **Impacted cerumen is an example of a sensory disturbance that is rooted in interference with the client's reception of stimuli

A client has expressed great relief at the improvement in her hearing after irrigation of her ear canal yielded a large amount of impacted cerumen (wax). This client was experiencing a sensory alteration related to which of the following? a. Sensory reaction b. Sensory perception c. Sensory transmission d. Sensory reception

c. Bargaining

A client has just been informed of a diagnosis of terminal cancer. The client states, "God has to have mercy on me because my children need me. He knows I'll change if he gets me through this." The nurse documents that the wife is expressing signs of which of Kubler-Ross's stages of grief? a. Denial b. Anger c. Bargaining d. Depression

c. Involuntary urination with minimal warning.

A client has urge incontinence. Which of the following signs and symptoms would the nurse expect to find in this client? a. Inability to empty the bladder. b. Loss of urine when coughing. c. Involuntary urination with minimal warning. d. Frequent dribbling of urine.

a. Cardiovascular disease

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? a. Cardiovascular disease b. Frequent urinary tract infections c. A history of migraine headaches d. Frequent upper respiratory infections

d. "I'm not quite sure I heard what you were saying about your work.

A client is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Which is the nurse's best response? a. "It's natural to worry about your job." b. "Your job must be very important to you." c. "Calm down so that I can understand what you're saying." d. "I'm not quite sure I heard what you were saying about your work.

a. Dilated pupils b. Diaphoretic c. Tachycardia

A client is informed of the need for surgery to correct a potentially life-threatening health problem. Afterward, the nurse determines that the client is experiencing physiological indicators of stress. What did the nurse assess to make this determination? (Select all that apply) a. Dilated pupils b. Diaphoretic c. Tachycardia d. Flaccid muscle tone e. Excessive oral secretions

a. "The type of surgery you are having is minor" c. "Everything will be all right" d. "You are not going to die"

A client is to have arthroscopic surgery of the knee to repair a torn tendon. The client says, "I don't know if I'll make it through this surgery." Which response by the nurse may block further communication by the client? (Select all that apply) a. "The type of surgery you are having is minor" b. "Surgery often can be frightening" c. "Everything will be all right" d. "You are not going to die" e. "You sound scared"

c. "on a scale of 0-10, how would you rate your pain?"

A client who had an elective below-the-knee amputation reports pain in the part of his leg that was amputated. What is the nurse's best response to his pain? a. "the pain will go away in a few days or so." b. "that's phantom limb pain and every amputee has that." c. "on a scale of 0-10, how would you rate your pain?" d. "the pain is not real, so we don't treat it."

c. report any worsening or unrelieved pain

A client who has fracture of the right tibia has had a cast applied. To teach the client how to observe and manage his cast extremity at home, the nurse should include which of the following instructions? a. use a blow dryer on a moderate hear setting to dry the cast after showering b. use a cotton swab to relieve itching under the cast c. report any worsening or unrelieved pain d. avoid moving the affected leg

c. "How do you take your prescribed blood pressure medications?"

A client with a history of hypertension presents to the clinic for an annual physical examination. The client reports a headache and the current blood pressure is 188/100 mm Hg. Which question by the nurse is priority based on the current data? a. "Has work been more stressful than usual lately?" b. "Have you taken any sinus or cold medications today?" c. "How do you take your prescribed blood pressure medications?" d. "How much processed food have you eaten over the past week?"

a. Assessing urinary intake and output.

A client with a very dry mouth, skin, and mucous membranes is diagnosed with dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit? a. Assessing urinary intake and output. b. Obtaining the client's weight weekly at different times of the day. c. Monitoring arterial blood gas (ABG) results. d. Maintaining I.V. therapy at the keep-vein-open rate.

c. Stage 1 hypertension

A client's blood pressure (BP) is 145/90. According to the guidelines for determining hypertension, the nurse realizes that the client's BP is at which stage? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

a. Changes in quantity and quality of sensory stimuli

A client, who lives alone in the country, was admitted to the hospital two days ago. The client begins to show signs of confusion and disorientation. You would most suspect which of the following problems as most contributing to the confusion and disorientation? a. Changes in quantity and quality of sensory stimuli b. Changes in the amount or type of medication c. Excessive worry about a variety of things d. A mental condition that has previously gone undetected

d. Forgetfulness gradually progressing to disorientation

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? a. Decreased auditory and visual acuity b. Decreased display of emotions c. Personality traits that are opposite of original traits d. Forgetfulness gradually progressing to disorientation

c. "I am still wishing I had gotten help to him sooner."

A grief support group is held at the local community center to assist persons who are dealing with issues of loss. Which remark by one of the members would the nurse interpret as indicating unresolved feelings of guilt? a. "I know that my husband had a good life." b. "It seems I miss my son more as time goes on." c. "I am still wishing I had gotten help to him sooner." d. "The Christmas season is always a sad time for me."

a. Calls the health care provider and questions the order **order is too vague. doesn't state site for patch or when to start it

A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: a. Calls the health care provider and questions the order b. Applies the patch the third postoperative day c. Applies the patch as soon as the patient reports pain d. Places the patch as close to the hip dressing as possible

b. Scatter rugs are present in the kitchen

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? a. Electrical cords are placed along the walls b. Scatter rugs are present in the kitchen c. Handrails are present in the bathroom d. Uses a microwave for cooking

a. "Dry between your toes after​ showering."​ b. "Apply moisturizing cream to feet and legs​ daily."

A home health nurse is caring for a client with peripheral vascular disease​ (PVD). When teaching the client regarding foot and leg​ care, which statement should the nurse​ include? (Select all that​ apply)​ a. "Dry between your toes after​ showering."​ b. "Apply moisturizing cream to feet and legs​ daily." c. Avoid using powder on your​ feet."​ d. "When swimming, ensure the water is​ cool, not​ warm."

b. Install locks at the tops of exterior doors **Alzheimer's pts are at an increased risk of wandering and getting lost

A home health nurse is providing teaching for the family of a client who has moderate Alzheimer's disease. The family plans to care for the client in the home. Which of the following recommendations should the nurse include in the teaching? a. Place nonskid rugs over smooth floors b. Install locks at the tops of exterior doors c. Provide clothing that has zippers instead of buttons d. Encourage the client to take frequent naps during the day

c. Contact a child abuse hotline.

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? a. Document her findings and treat the patient. b. Instruct the mother on safe handling of a 2-year-old child. c. Contact a child abuse hotline. d. Discuss this story with a colleague.

c. The client complains of a headache and blurred vision.

A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician? a. Blood pressure reading is at the prenatal baseline. b. Urinary output has increased. c. The client complains of a headache and blurred vision. d. Dependent edema has resolved.

c. Ask if the patient would like to talk about his feelings

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient? a. Give the patient a hug and tell him that his life still has meaning b. Arrange for a spiritual adviser to visit the patient c. Ask if the patient would like to talk about his feelings d. Call in a close friend or relative to talk to the patient

d. the client developed a tolerance to the medication

A hospice nurse us caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain relief. Which of the following scenarios should the nurse document as the explanation for this situation? a. the client not been taking the medication properly b. the client is experiencing episodes of confusion c. the client has become addicted to the medication d. the client developed a tolerance to the medication

c. Assess for factors that might be causing discomfort **Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to do which of the following? a. Reorient the patient to time, place, and person b. Administer the PRN dose of lorazepam (Ativan) c. Assess for factors that might be causing discomfort d. Have a nursing assistant stay with the patient to ensure safety

a. Maintain patient safety

A major goal of treatment for the patient with Alzheimer's disease is to do which of the following? a. Maintain patient safety b. Maintain or increase body weight c. Return to a higher level of self-care d. Enhance functional ability over time

c. "Infants start walking sideways while holding onto furniture before walking or standing alone"

A mother expresses concern because her infant is walking sideways while holding onto furniture. Which of the following is the appropriate statement the nurse should make to this mother? a. "You may want to consider a neurological evaluation to rule out a pathological cause for this behavior" b. "If you will hold the baby's hands while the baby walks, you can break the baby of this habit" c. "Infants start walking sideways while holding onto furniture before walking or standing alone" d. "You need to make an appointment with your pediatrician and have this problem checked out"

a. "This is normal for this age. The pincer grasp isn't mastered until 9-11 months old"

A mother tells the nurse that her 6-month-old child is grasping things such as a spoon in the palms and asks when the child will be able to grasp a spoon between the thumb and fingers. The appropriate response by the nurse would be: a. "This is normal for this age. The pincer grasp isn't mastered until 9-11 months old" b. "Encourage your child to play with an older child who uses the pincer grasp and your child will pick up the skill from the other child" c. "Begin teaching your baby to use the pincer grasp. It will take time" d. "I will ask your physician about doing developmental testing to evaluate your baby's level of development"

b. iron-fortified cereal

A new nurse is providing education about introducing new foods to the guardians of a 4-month-old infant. The nurse should recommend that the caregivers introduce which of the following foods first? a. strained yellow vegetables b. iron-fortified cereal c. pureed fruits d. whole milk

a. Consult the medication reference book available on the unit

A newly licensed nurse is preparing to administer a medication to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? a. Consult the medication reference book available on the unit b. Ask a more experienced nurse for information on the medication c. Call the client's provider and verify the prescription d. Ask the client if she takes this medication at home

d. Assess the patient for adverse effects

A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority? a. Complete an occurrence report b. Notify the health care provider c. Inform the charge nurse of the error d. Assess the patient for adverse effects

b. Decreased blood glucose **Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery.

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. Which planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? a. Hyperthermia b. Decreased blood glucose c. Rapid pulse rate d. Irritability

c. Overflow incontinence

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? a. Stress incontinence b. Urge incontinence c. Overflow incontinence d. Reflex incontinence

c. Breakthrough pain

A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? a. Phantom limb pain b. Mixed pain c. Breakthrough pain d. Neuropathic pain

a. "They are tablets administered vaginally"

A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? a. "They are tablets administered vaginally" b. "They act by absorbing fluid from tissues" c. "They promote dilation of the os" d. "They include an amniotomy"

d. preparation

A nurse has made a commitment to change his eating habits to optimize his health and wellness. He researches various dietary plans and narrows his choices to those that minimize the effect of lifestyle barriers, like eating quickly at work. Which stage of the transtheoretical model is he in? a. contemplation b. action c. maintenance d. preparation

c. assessment

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? a. planning b. evaluation c. assessment d. implementation

d. Neural tube defects

A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? a. Iron deficiency anemia b. Poor bone formation c. Macrosomic fetus d. Neural tube defects

b. Denial

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again". The nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving? a. Bargaining b. Denial c. Depression d. Anger

d. "I am your nurse. Let's walk together to your room"

A nurse in a long-term care facility is caring for a client who has Alzheimer's and tries to wander out of the building. The client states, "I have to get home". Which of the following statements should the nurse make? a. "You have forgotten that this is your home" b. "You cannot go outside without a staff member" c. "Why would you want to leave? Aren't you happy here?" d. "I am your nurse. Let's walk together to your room"

c. Take the client to the bathroom every 2 hours

A nurse in a longterm care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? a. Remind the client to tell the nurse when has has to urinate b. Use adult diapers to prevent frequent clothing changes c. Take the client to the bathroom every 2 hours d. Request a prescription for an indwelling catheter

a. A client at 11 weeks gestation and reports abdominal cramping **Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion.

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? a. A client at 11 weeks gestation and reports abdominal cramping b. A client at 15 weeks gestation and reports tingling and numbness c. A client at 20 weeks gestation and reports constipation for the past 4 days d. A client at 8 weeks gestation and reports having 3 bloody noses in the past week

a. Client has delivered one newborn at term d. Client has had two prior pregnancies e. Client has one living child **P0 indicates no preterm DELIVERIES, not labor; A1 indicates she has has had one prior miscarriage/spontaneous abortion

A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply) a. Client has delivered one newborn at term b. Client has experienced no preterm labor c. Client has been through active labor d. Client has had two prior pregnancies e. Client has one living child

d. "A weight gain of about 25 to 35 pounds is good" **A gain of 4 lb in the first trimester and 12 lb each for the second and third trimester is recommended.

A nurse in a prenatal clinic is caring for a client who is within the recommended guidelines for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make? a. "Your provider can discuss an appropriate amount of weight gain with you" b. "A weight gain of about 14 pounds each trimester is suggested" c. "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant" d. "A weight gain of about 25 to 35 pounds is good"

b. 3.6 kg (8 lbs) weight gain and is in the first trimester **they exceeded the expected 3-4 lb weight gain that occurs in the first trimester

A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? a. 1.8 kg (4 lbs) weight gain and is in the first trimester b. 3.6 kg (8 lbs) weight gain and is in the first trimester c. 6.8 kg (15 lbs) weight gain and is in the second trimester d. 11.3 kg (25 lbs) weight gain and is in the third trimester

b. affective **affective learning because the client's feelings about toilet training have been changed

A nurse in a provider's office is collecting data from the caregiver of a 1-year-old who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? a. cognitive b. affective c. psychomotor d. kinesthetic

b. Toddlers

A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel play in which of the following age groups? a. Infants b. Toddlers c. Preschoolers d. School-age children

a. Cardiac dysrhythmias

A nurse in a providers office is reviewing the laboratory results of a client who takes furosemide for hypertension. the nurse notes that the clients potassium level is 3.3 mEq/L. the nurse should monitor the client for which of the following complications? a. Cardiac dysrhythmias b. Hypoglycemia c. Seizures d. Neurogenic shock

d. Pregestational diabetes mellitus

A nurse in a providers office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following finding should the nurse identify as a risk factor for the development of preeclampsia? a. Singleton pregnancy b. BMI of 20 c. Maternal age of 32 years d. Pregestational diabetes mellitus

d. Establish a reward system for positive behavior.

A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care? a. Allow for adjustment of rules to correlate with the child's behavior b. Provide a flexible schedule that adjusts to the child's interest. c. Allow for imaginative play with peers without supervision. d. Establish a reward system for positive behavior.

d. restating

A nurse in an acute mental health facility is communicating with a client. A client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? a. offering general leads b. summarizing c. focusing d. restating

a. Instruct the client about vena cava syndrome and measures to prevent it **This is the typical finding of vena cava syndrome, or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side lying position promotes uterine perfusion and fetoplacental oxygenation.

A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I become very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take? a. Instruct the client about vena cava syndrome and measures to prevent it b. Arrange for the client to come to the clinic for an assessment c. Check the client's chart for gestational diabetes mellitus d. Schedule a nonstress test for the client

a. Denial

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 exam room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions? a. Denial b. Displacement c. Projection d. Undoing

c. "This is due to the weight of the uterus on the vena cava"

A nurse in the prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks what causes this. Which of the following responses should the nurse make? a. "This is due to an increase in blood volume" b. "This is due to pressure from the uterus on the diaphragm" c. "This is due to the weight of the uterus on the vena cava" d. "This is due to increased cardiac output"

c. "I just can't believe that this dialysis is going to ruin my whole life"

A nurse is a caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? a. "I know that I will get a kidney transplant. I am a good candidate" b. "I can now eat whatever I want. The dialysis will remove it from my system" c. "I just can't believe that this dialysis is going to ruin my whole life" d. "I know that kidney disease runs in my family, but I can prevent it"

a. Paralysis of a client's lower extremities following epidural anesthesia

A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? a. Paralysis of a client's lower extremities following epidural anesthesia b. A client fall during ambulation did not result in client injury c. Surgery to the wrong site was stopped prior to surgery d. A client's family complained that a nurse was culturally insensitive

a. Respirations less than 12/min b. Urinary output less than 25 mL/hr d. Decreased level of consciousness

A nurse is administering magnesium sulfate IV for seizure prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? (Select all that apply) a. Respirations less than 12/min b. Urinary output less than 25 mL/hr c. Hyperreflexic DTRs d. Decreased level of consciousness e. Flushing and swelling

d. When asking if the client took his medications this morning **A "yes" or "no" response is sufficient when asking if a client took his morning medications. If he did not take them and should have, the nurse might want to explore the issue further.

A nurse is admitting a client from a long-term care facility. The nurse should use close-ended questions when assessing which of the following factors? a. When determining if the client is eating a well-balanced diet. b. When asking the client about his receptiveness to the transfer. c. When asking the client how he completes his ADLs. d. When asking if the client took his medications this morning

d. Begin FHR monitoring

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke". Which of the following interventions is the nurse's priority? a. Perform Nitrazine testing b. Assess the fluid c. Check cervical dilation d. Begin FHR monitoring

a. Maintain continuous passive motion device b. Palpate dorsalis pedal pulses d. Elevate heels off bed

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply.) a. Maintain continuous passive motion device b. Palpate dorsalis pedal pulses c. Place pillow behind the knee d. Elevate heels off bed e. Apply heat therapy to incision.

b. "I understand that you believe this is true, and it must be very frightening for you"

A nurse is admitting a client who has schizophrenia. The client states, "The FBI has bugged the phone and is monitoring my calls". Which of the following responses by the nurse is appropriate? a. "You are wrong about the phone being bugged, and you should recognize that you're having delusional thoughts" b. "I understand that you believe this is true, and it must be very frightening for you" c. "I know it is difficult for you to talk to me while you are having paranoid ideas" d. "Do you realize how crazy that sounds?"

a. obtain blood samples for baseline lab values **obtain samples of client's blood for baseline testing of hemoglobin and hematocrit levels.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. What action should the nurse take? a. obtain blood samples for baseline lab values b. place a spiral electrode on the fetal presenting part c. prepare the client for a transvaginal ultrasound d. perform a vaginal exam to determine cervical dilation

a. Abruptio placenta **Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. Abruptio placenta b. Placenta previa c. Preeclampsia d. Maternal bradycardia

c. "You appear to be feeling anxious"

A nurse is admitting a client who is scheduled to undergo a cardiac catheterization. The client says, "My coworker died last week from a heart attack". Which of the following responses should the nurse offer? a. "Your provider will not let that happen because she knows how to treat your condition" b. "Do you think the same thing will happen to you?" c. "You appear to be feeling anxious" d. "Has anyone in your family had a heart attack?"

a. Decreased skin turgor b. Concentrated urine d. Low-grade fever e. Tachypnea

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply) a. Decreased skin turgor b. Concentrated urine c. Bradycardia d. Low-grade fever e. Tachypnea

a. Dyspnea b. Edema d. Hypertension e. Weakness

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lbs) in 48 hours. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply) a. Dyspnea b. Edema c. Bradycardia d. Hypertension e. Weakness

a. continue routine monitoring

A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion

c. birth weight doubled **should have tripled by this point

A nurse is assessing a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. closed anterior fontanel b. eruption of six teeth c. birth weight doubled d. birth length increased by 50%

b. head circumference exceeds chest circumference **head and chest circumference should be equal by 1-2 years of age

A nurse is assessing a 2 1/2 year old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? a. height increased by 7.5 cm (3 inches) in the past year b. head circumference exceeds chest circumference c. anterior and posterior fontanels are closed d. current weight equals four times the birth weight

a. this will resolve within 3-6 wks without treatment **This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum, that will resolve within 2 to 6 weeks.

A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? a. this will resolve within 3-6 wks without treatment b. this will resolve on its own within 3-4 days c. this is expected at birth so you don't need to worry about it d. the provider might drain this area with a syringe

a. sleeps 14-16 hours per day d. current weight same as birth weight **fontanels don't close until about 2-3 months, and the pincer grasp is not evident until about 9 months

A nurse is assessing a 2-week-old newborn during a routine checkup. Which of the following findings should the nurse expect? (Select all that apply) a. sleeps 14-16 hours per day b. posterior fontanel closed c. pincer grasp present d. current weight is the same as birth weight

b. place the naked newborn on the mothers bare chest and cover both with a blanket **Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.

A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings

a. Closed posterior fontanel

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? a. Closed posterior fontanel b. Uses thumb and index fingers in a pincer grasp c. Crawling d. Sitting steadily without support.

c. Tap lightly on the client's cheek

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. Apply a blood pressure cuff to the client's arm b. Place the stethoscope bell over the client's carotid artery c. Tap lightly on the client's cheek d. Ask the client to lower their chin to their chest

c. Ask the client when she last voided **The fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.

A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take? a. Report the vital signs to the provider b. Massage the fundus c. Ask the client when she last voided d. Administer an oxytocic agent

a. Intense pain when the client's left foot is passively moved c. Hard, swollen muscle in the client's left leg d. Burning and tingling of the client's left foot e. Client report of minimal pain relief following a second dose of opioid medication

A nurse is assessing a client who had an external fixation device applied 2 hours ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? (Select all that apply) a. Intense pain when the client's left foot is passively moved b. Capillary refill of 3 sec on the client's left leg c. Hard, swollen muscle in the client's left leg d. Burning and tingling of the client's left foot e. Client report of minimal pain relief following a second dose of opioid medication

a. Altered mental status

A nurse is assessing a client who has a casted fracture of the femur. Which of the following findings is a manifestation of a fat emboli? a. Altered mental status b. Reduced bowel sounds c. Swelling of the toes distal to the injury d. Pain with passive movement of the foot distal to the injury

c. Severe eye pain **Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? a. Multiple floaters b. Flashes of light in front of the eye c. Severe eye pain d. Double vision

b. Opacity visible behind pupil

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? a. Pupils nonreactive to light b. Opacity visible behind pupil c. White circle around the outside border of the iris d. Increased intraocular pressure

b. Edema

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? a. Dependent rubor b. Edema c. Hair loss d. Thick, deformed toenails

a. Increased heart rate b. Increased blood pressure c. Increased respiratory rate

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply) a. Increased heart rate b. Increased blood pressure c. Increased respiratory rate d. Increased hematocrit e. Increased temperature

d. Presence of ketones in the urine **Ketonuria due to inadequate dietary intake, resulting in the breakdown of protein and stored fat

A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? a. Elevated serum potassium level b. Rapid weight gain c. Peripheral edema d. Presence of ketones in the urine

c. Weak, irregular pulse

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? a. Hyperactive bowel sounds b. Extreme thirst c. Weak, irregular pulse d. Hyperactive reflexes

c. Enlarged joint size d. Limp when walking

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (Select all that apply) a. Swelling of all joints b. Small body frame c. Enlarged joint size d. Limp when walking

a. Widened pulse pressure **A widening of the pulse pressure, the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.

A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? a. Widened pulse pressure b. Tachycardia c. Periorbital edema d. Decreased urine output

b. Vaginal pressure **expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? a. Lochia serosa vaginal drainage b. Vaginal pressure c. Intermittent vaginal pain d. Yellow exudate vaginal drainage

d. assist the client to empty her bladder

A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder

b. Measure the height of the fundus in fingerbreadths in relation to the umbilicus

A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? a. Press down and forward with the hand that is placed on the base of the uterus b. Measure the height of the fundus in fingerbreadths in relation to the umbilicus c. Place the client in a semi-Fowler's position prior to checking the uterus d. Massage the fundus with gentle palpation until it becomes soft to touch

c. dark red vaginal bleeding

A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding should the nurse expect? a. decreased urinary output b. fetal distress c. dark red vaginal bleeding d. increased platelet count

a. 480 mL urine output in 24 hrs

A nurse is assessing a client who is at 35 weeks of gestation and has mild preeclampsia without severe features. What finding should the nurse identify as the priority? a. 480 mL urine output in 24 hrs b. 1+ protein in the urine c. +2 edema of the feet d. BP 144/92

d. urinary output 20 mL/hr **can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity

A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to the provider? a. DTR 2+ b. resp 16 c. BP 150/96 d. urinary output 20 mL/hr

a. uterine contractions

A nurse is assessing a client who is at 37 weeks gestation and has a suspected pelvic fracture due to blunt and trauma. What findings should the nurse expect? a. uterine contractions b. bradycardia c. seizures d. bradypnea

c. Weight gain of 2.2 kg (4.8 lbs) **A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood pressure 136/88 mm Hg b. Reports of insomnia c. Weight gain of 2.2 kg (4.8 lbs) d. Report of Braxton Hicks contractions

d. Tachycardia

A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? a. Moist skin b. Distended neck veins c. Increased urinary output d. Tachycardia

b. Viral infection

A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? a. Hypotension b. Viral infection c. Increased energy d. Increased cognitive awareness

b. Proteinuria

A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? a. Severe hypotension b. Proteinuria c. Elevated platelet count d. Seizures

c. slow trickle of bright vaginal bleeding and a firm fundus **The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? a. a gush of rubra lochia when the nurse massages the uterus b. continuous lochia flow and flaccid uterus c. slow trickle of bright vaginal bleeding and a firm fundus d. report of increasing pain and pressure in the perineal area

b. Urinary output 40 mL in 2 hours **Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is less than 30 mL/hr.

A nurse is assessing a client who is receiving magnesium sulfate as treatment for preeclampsia. Which of the following clinical findings is the nurse's priority? a. Respiration 16/min b. Urinary output 40 mL in 2 hours c. Reflexes 2+ d. FHR 158/min

c. Naloxone

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medication should the nurse administer? a. Fentanyl b. Butorphanol c. Naloxone d. Meperidine

b. Pain when bearing weight c. Joint crepitus d. Swelling of the affected joint e. Limited joint motion

A nurse is assessing a client who is to undergo a right knee arthroplasty. Which of the following are expected findings? (Select all that apply.) a. Skin reddened over the joint b. Pain when bearing weight c. Joint crepitus d. Swelling of the affected joint e. Limited joint motion

a. Cataracts

A nurse is assessing a client who reports an acute visual disturbance that he describes as decreased color perception and blurry vision. The nurse should notify the provider that this client might have which of the following disorders? a. Cataracts b. Angle-closure glaucoma c. Retinal detachment d. Macular degeneration

a. Nausea in the morning

A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy? a. Nausea in the morning b. Positive home pregnancy test c. Increased sensitivity of the cervix noted upon examination d. Palpated fetal movement by provider

d. "I feel so empty without my wife that it's hard to get up every morning"

A nurse is assessing a client whose partner died 4 months ago. Which of the following indicates that the client is at risk of complicated grief? a. "I wish I had been more generous to my wife before she died" b. "I told my wife to go to the doctor, but she would not listen to me" c. "I think about my wife all the time when I go to outings with my family" d. "I feel so empty without my wife that it's hard to get up every morning"

d. Pallor on elevation of the limbs, and rubor when the limbs are dependent

A nurse is assessing a client with chronic PAD. Which of the following findings should the nurse expect? a. Edema around the ankles and feet b. Ulceration around the medial malleoli c. Scaling eczema of the lower legs d. Pallor on elevation of the limbs, and rubor when the limbs are dependent

d. Respiratory distress **Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? a. Hypertonia b. Increased feeding c. Hyperthermia d. Respiratory distress

b. Leg pain at rest

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect? a. Thin, pliable toe nails b. Leg pain at rest c. Hairy legs d. Flushed, warm legs

b. jaundice of the sclera

A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? a. acrocyanosis b. jaundice of the sclera c. resp rate 50/min d. blood glucose 60 mg/dL

b. 9 **Assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.

A nurse is assessing a newborn 1 min after birth and notes a HR of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What APGAR score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7

a. Minimal arm recoil

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? a. Minimal arm recoil b. Popliteal angle of 90 c. Creases over the entire foot sole d. Raised areolas with 3 to 4 mm buds

c. Petechiae over the head

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? a. Brusing over the buttocks b. Hard nodules on the roof of the mouth c. Petechiae over the head d. Bilaterl periauricular papillomas

a. Leaves the child's room exactly as it was before the loss

A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is experiencing manifestations of prolonged grieving? a. Leaves the child's room exactly as it was before the loss b. Volunteers at a local children's hospital c. Talks about the child in the past tense d. Visits the child's grave every week after worship services

c. Lightening

A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports her breathing has become easier, but notes an increased frequency of urination. The nurse should document this occurrence as which of the following? a. Effacement b. Dilation c. Lightening d. Quickening

d. Cystitis

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? a. Nephrosclerosis b. Uremia c. Diverticulitis d. Cystitis

d. A client who has a temperature of 39 degrees C (102 degrees F)

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? a. A client who has a urine specific gravity of 1.010 b. A client who has a weight gain of 2.2 kg (2 lbs) in 24 hours c. A client who has a hematocrit of 45% d. A client who has a temperature of 39 degrees C (102 degrees F)

d. A newborn who is 18 hours old and has an axillary temperature of 37.7°C (99.9°F) **An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who is 26 hours old and has erythema toxicum on his face b. A newborn who is 32 hours old and has not passed a meconium stool c. A newborn who is 12 hours old and has pink-tinged urine d. A newborn who is 18 hours old and has an axillary temperature of 37.7°C (99.9°F)

a. Pitting edema around the stump dressing

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? a. Pitting edema around the stump dressing b. Looseness of the stump dressing c. The dressing forms a cone shape over the stump d. Figure-eight wrapping around the stump

c. I will apply fresh linens and place a clean gown on the body d. I will remove all equipment from the bedside e. I will dim the lights in the room

A nurse is assisting a newly licensed nurse with postmortem care to a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of this procedure? (Select all that apply) a. I will remove the dentures from the body b. I will make sure the body is lying completely flat c. I will apply fresh linens and place a clean gown on the body d. I will remove all equipment from the bedside e. I will dim the lights in the room

a. Client concerns **Information the nurse obtains directly from the client is generally the most accurate and provides the best information available. The client is a primary source of information.

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client? a. Client concerns b. Family information. c. Medical history d. Progress note

a. Assume an open position

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? a. Assume an open position b. Sit upright and lean back into the chair c. Avoid direct eye contact until the client initiates it d. Sit directly next to the client

a. Large building blocks

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? a. Large building blocks b. Hanging crib toys c. Modeling clay d. Crayons and a coloring book

b. The client's husband died seven months ago **One of the defining factors of maladaptive grieving if grief that last 6 months or longer after the loss

A nurse is caring for a 48 year old client who is grieving. The client reports that her husband died seven months ago, that she has lost 30 lb, and that she has difficulty sleeping. Which of the following item of data indicate that the client is experiencing maladaptive grieving? a. The client is 48 years old b. The client's husband died seven months ago c. The client has lost 30 lb d. The client has difficulty sleeping

b. Stop the infusion

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Which of the following actions should the nurse perform FIRST? a. Elevate the extremity b. Stop the infusion c. Apply warm/cold compresses d. Remove the IV catheter

a. maintain an abduction pillow between the legs

A nurse is caring for a client following a left hip arthroplasty. Which of the following should the nurse implement to prevent dislocation? a. maintain an abduction pillow between the legs b. encourage use of elastic stockings c. monitor for shortening of the affected leg d. avoid flexing the hips more than 60 degrees

a. first stage, latent phase

A nurse is caring for a client having contractions every 8 minutes that are 30-40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is this client experiencing? a. first stage, latent phase b. first stage, active phase c. first stage, transition phase d. second stage of labor

d. Monitor for orthostatic hypotension

A nurse is caring for a client in a long-term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.3 C (100.9 F), pulse 92/min, respirations 20/min, and blood pressure 108/60. Which of the following actions should the nurse take? a. Initiate fluid restrictions to limit intake b. Check for peripheral edema c. Encourage the client to ambulate to promote oxygenation d. Monitor for orthostatic hypotension

a. Elicit information from the client.

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? a. Elicit information from the client. b. Encourage the client to use self-exploration. c. Review the client's progress toward the personal objectives. d. Talk with others who have information about the client.

a. Lengthening of umbilical cord d. Appearance of dark blood from the vagina e. Fundus firm upon palpation

A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? (Select all that apply) a. Lengthening of umbilical cord b. Swift gush of amniotic fluid c. Softening of the lower uterine segment d. Appearance of dark blood from the vagina e. Fundus firm upon palpation

c. use intermittent eye contact

A nurse is caring for a client using active listening skills. Which of the following actions should the nurse take? a. sit side-by-side with the client b. have a pen and paper handy c. use intermittent eye contact d. lean back in the chair

c. stress management lecture **primary prevention is true prevention of the manifestations of illness through health promotion and disease prevention. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness.

A nurse is caring for a client who attended a blood pressure screening event and a stress management lecture at a community fair. His BP was 150/94 at the event, so he saw a provider at the clinic and began beta blocker therapy. Soon after, the client had a mild myocardial infarction, and after discharge, enrolled in a cardiac rehab program. Which of the following activities of this client is an example of primary prevention? a. blood pressure screening b. cardiac rehab c. stress management lecture d. beta blocker therapy

a. Palpable fetal movement

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? a. Palpable fetal movement b. Chadwick's sign c. Positive pregnancy test d. Amenorrhea

c. Palpating the client's fundus **this will reduce postpartum hemorrhage and uterine atony

A nurse is caring for a client who had a precipitous delivery. Which of the following is the priority during the fourth stage of labor? a. Obtaining the client's temperature b. Inspecting the client's perineum c. Palpating the client's fundus d. Checking the client for hemorrhoids

b. Place the client in a room near the nurses' station

A nurse is caring for a client who has Alzheimer's and falls frequently. Which of the following actions should the nurse take first to keep the client safe? a. Keep the call light near the client b. Place the client in a room near the nurses' station c. Encourage the client to ask for assistance d. Remind the client to walk with someone for assistance

a. ECG changes

A nurse is caring for a client who has a blood potassium level of 5.4 mEq/L. The nurse should assess for which of the following manifestations? a. ECG changes b. Constipation c. Polyuria d. Paresthesia

a. Complete a fall-risk assessment **this will work as a guide in implementing appropriate safety measures

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's first priority? a. Complete a fall-risk assessment b. Educate the client and family about fall risks c. Eliminate safety hazards from the client's environment d. Make sure the client uses assistive aids in their possession

b. Hyponatremia

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? a. Hypercalcemia b. Hyponatremia c. Hyperphosphatemia d. Hyperkalemia

a. ask the dietician to assist with meal planning b. contact the client's support system d. encourage the use of a daily medication dispenser e. provide educational materials for home use

A nurse is caring for a client who has a new diagnosis of type 2 diabetes and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following actions should the nurse take to promote client compliance? (Select all that apply) a. ask the dietician to assist with meal planning b. contact the client's support system c. assess for age-related cognitive awareness d. encourage the use of a daily medication dispenser e. provide educational materials for home use

b. Allow the client to provide input in the treatment plan c. Assist the client with time management, and address the client's priorities e. Encourage the client in the expression of feelings and concerns

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan would be appropriate at this time? (Select all that apply) a. Suggest coping skills for the client to utilize in this situation b. Allow the client to provide input in the treatment plan c. Assist the client with time management, and address the client's priorities d. Provide extensive instructions on the client's treatment regimen e. Encourage the client in the expression of feelings and concerns

b. methergine

A nurse is caring for a client who has a soft uterus and increased lochia. What meds should the nurse plan to administer to promote uterine contractions? a. mag sulfate b. methergine c. terbutaline d. nifedipine

d. Methergine

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? a. Terbutaline b. Nifedipine c. Magnesium sulfate d. Methergine

b. sit the client upright in bed

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 and apical HR 54/min. Which of the following actions should the nurse take first? a. examine skin for irritation or pressure b. sit the client upright in bed c. check the urinary catheter for blockage d. administer antihypertensive medication

d. Decreased muscle tone

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse about anticipated findings at this time. which of the following findings should the nurse include in the discussion? a. Regular breathing patterns b. Warm extremities c. Increased urine output d. Decreased muscle tone

c. "Let's set up a meeting time with the doctor to discuss your options for home care"

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? a. "Social services can contact various community resources that will be helpful" b. "I will review the care plan to make the necessary changes" c. "Let's set up a meeting time with the doctor to discuss your options for home care" d. "I will make a list of things we need to do before discharge"

b. Rapid fluctuation in level of consciousness

A nurse is caring for a client who has acute delirium. Which of the following findings should the nurse expect? a. Progressive deterioration of cognitive function b. Rapid fluctuation in level of consciousness c. Loss of language ability d. Absence of contributing factors to pinpoint the cause of delirium

c. the nurse asks the client about personal body image perception

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? a. the nurse discusses the client's weight loss during the health care team meeting b. the nurse examines her own personal feelings about clients with anorexia nervosa c. the nurse asks the client about personal body image perception d. the nurse presents an educational session about anorexia nervosa to a large group of adolescents

c. "The doctor says I only have a few months to live, but I know he was exaggerating to get me to take my medication"

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process? a. "The doctor has been so good to me. I know he has tried everything he can. It's just my time" b. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer" c. "The doctor says I only have a few months to live, but I know he was exaggerating to get me to take my medication" d. Even though I am not hurting now, I don't feel like I have the energy to get out of bed

b. Apply the stockings in the morning upon wakening and before getting out of bed

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? a. Elevate the client's legs for 10 minutes, 2-3 times per day while wearing stockings b. Apply the stockings in the morning upon wakening and before getting out of bed c. Roll the stockings down to the knees to relieve discomfort on the legs d. Remove the stockings while out of bed for 1 hr, 4 times a day to allow the legs to rest

d. Pelvic inflammatory disease (PID) **Most cases of an ectopic pregnancy are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk for an ectopic pregnancy.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? a. Anemia b. Frequent urinary tract infections c. Previous cesarean birth d. Pelvic inflammatory disease (PID)

c. "Tell me what you like to cook for dinner."

A nurse is caring for a client who has dementia due toAlzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse Is appropriate? a. "This is where you live now." b. "This is a safer place for you to live." c. "Tell me what you like to cook for dinner." d. "Your family said there is no one to care for you at home."

b. Maintain a low-stimulation environment

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? a. Assign the client several tasks at the same time b. Maintain a low-stimulation environment c. Advise family to visit frequently as a group d. Encourage the client to make choices regarding care.

d. "It seems as though you're expressing feelings of hopelessness"

A nurse is caring for a client who has depression. The client states, "Things are always going to be bad for me. I wish I could just go to sleep and forget about all my problems". Which of the following is an appropriate response by the nurse? a. "Tell me about the dynamics of your family" b. "Why do you feel this way?" c. "It seems as though you're expressing feelings of hopelessness"

b. Open-angle glaucoma

A nurse is caring for a client who has diabetes and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? a. Cataracts b. Open-angle glaucoma c. Macular degeneration d. Angle-closure glaucoma

a. Reduce the IV fluid rate **reduce the IV rate and notify the provider immediately

A nurse is caring for a client who has fluid overload following continuous IV infusion of 200 mL/hr. Which of the following actions by the nurse is appropriate? a. Reduce the IV fluid rate b. Place the client in the orthopneic position c. Remove the IV catheter d. Place the client in modified Trendelenburg

c. 0.45% sodium chloride **Lactated Ringer's is isotonic IV solution, which will not help correct the client's sodium elevation. Dextrose 5% in 0.9% sodium chloride is a hypertonic IV solution, which will not help correct the client's sodium elevation. Dextrose 10% in water is a hypertonic IV solution, which will not help correct the client's sodium elevation

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? a. Lactated Ringer's b. Dextrose 5% in 0.9% NaCl c. 0.45% sodium chloride d. Dextrose 10% in water

a. "You seem upset about taking your blood pressure medication"

A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection? a. "You seem upset about taking your blood pressure medication" b. "Why do you feel afraid to take your medication?" c. "You won't get better until you take your medication" d. "Did your symptoms occur before or after you took the medication?"

a. Urine output of 175 mL in the past 8 hours

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? a. Urine output of 175 mL in the past 8 hours b. Urine output of 2,200 mL in the last 24 hours c. First voided urine in the morning has a strong odor d. Urine is cloudy after sitting in the urinal for 6 hours

a. Assist the client to the correct room

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? a. Assist the client to the correct room b. Place the client in restraints c. Reorient the client to time and place d. Move the client to a room at the end of the hall

c. Speak directly to the client in a normal, clear voice

A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take? a. Speak loudly and into the client's good ear b. Use sign language when communicating with the client c. Speak directly to the client in a normal, clear voice d. Sit by the client's side and speak very slowly

c. Provide a private room, and limit stimulation.

A nurse is caring for a client who has sensory overload. Which of the following interventions should the nurse implement? a. Immediately complete a thorough assessment. b. Put the client in a room with a client who is hearing impaired. c. Provide a private room, and limit stimulation. d. Talk loudly to the client, and encourage ambulation.

c. Bargaining

A nurse is caring for a client who has stage IV lung cancer and is 3 days postop following a wedge resection. the client states, i told myself that i would go through with the surgery if i quit smoking, if i could just live long enough to attend my daughters wedding.based on Kubler-Ross' model, which stage of grief is the client experiencing? a. Anger b. Denial c. Bargaining d. Acceptance

b. Urine ketones present

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition? a. Hgb 12.2 g/dL b. Urine ketones present c. ALT 20 IU/L d. Blood glucose 114 mg/dL

c. The client's sense of loss can be lessened through retaining control of certain areas of her life

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. which of the following rationales for self-care should the nurse communicate to the family? a. Allowing the client to function independently will strengthen her muscles and promote healing b. The client needs to be given privacy at times for self- reflecting and organizing her life. c. The client's sense of loss can be lessened through retaining control of certain areas of her life d. Performing ADLs is required prior to discharge from an acute care facility

b. align her feet vertically with her shoulders

A nurse is caring for a client who immobile. Which of the following actions should she perform when repositioning the client to avoid injuring her own musculoskeletal system? a. adjust the bed to its lowest position b. align her feet vertically with her shoulders c. stand slightly away from the bed when turning the client d. bend her back when lifting the client

b. Massage the fundus

A nurse is caring for a client who is 2 hours postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? a. Check for a full bladder b. Massage the fundus c. Measure vital signs d. Administer Carboprost IM

d. Instruct the client to apply cold compresses

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? a. Encourage the client to pump the breasts b. Instruct the client to take a warm shower twice per day c. Tell the client to massage her breasts d. Instruct the client to apply cold compresses

c. Administer oxygen via a nonrebreather mask **do this to ensure adequate oxygenation to the fetus

A nurse is caring for a client who is at 26 weeks gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? a. Monitor the FHR b. Assess uterine activity c. Administer oxygen via a nonrebreather mask d. Start a bolus of IV fluids

c. you should walk for at least 30 minutes every day

A nurse is caring for a client who is at 26 wks gestation and reports constipation. What responses by the nurse is appropriate? a. you should drink 1 ounce of mineral oil every morning b. you should eat at least 3 ounces of red meat/day c. you should walk for at least 30 minutes every day d. you should stop taking your prenatal vitamins

c. Respiratory rate 10/min

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? a. Client reports nausea b. Urinary output of 40 mL/hr c. Respiratory rate 10/min d. Client reports feeling flushed

a. Betamethasone **administer betamethasone to stimulate fetal lung maturity and thereby prevent respiratory depression

A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? a. Betamethasone b. Misoprostol c. Methylergonovine d. Cytotec

d. "My heart feels as if it is racing"

A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? a. "My ankles are swollen at the end of the day" b. "I can feel the baby kicking my ribs, and it is very uncomfortable" c. "I'm growing more and more worried every day" d. "My heart feels as if it is racing"

a. daily weights

A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia. What assessment provides the most accurate info regarding the client's fluid and electrolyte status? a. daily weights b. blood pressure c. severity of edema d. intake and output

a. auscultate for a FHR **presence of a fetal heart rate is a reassuring manifestation of fetal well-being --> auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for 24 hr. What action should the nurse take? a. auscultate for a FHR b. reassure the client that a term fetus is less active c. have the client drink orange juice d. palpate the uterus for fetal movement

d. Check the cervix prior to analgesic administration **Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care? a. Keep the side rails up while the client is in bed b. Monitor fetal heart rate every hour c. Insert an indwelling urinary catheter d. Check the cervix prior to analgesic administration

c. uteroplacental insufficiency **late deceleration in the FHR results from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.

A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor. The nurse observes late decels in the FHR. What finding should the nurse identify as the cause of late decels? a. umbilical cord compression b. fetal head compression c. uteroplacental insufficiency d. fetal ventricular septal defect

c. Meconium aspiration **postterm infant is at risk for hypoglycemia, not hyper; posterm pregnancies result in oligohydramnios, not polyhydramnios; IUGR occurs much eariler in pregnancy

A nurse is caring for a client who is at 42 weeks gestation and in active labor. Which of the following findings is the fetus at risk for developing? a. IUGR b. Hyperglycemia c. Meconium aspiration d. Polyhydramnios

b. "These feelings are quite normal at the beginning of pregnancy" **This client needs reassurance that these feelings are normal and there is no reason for concern.

A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make? a. "Have you told your husband about these feelings?" b. "These feelings are quite normal at the beginning of pregnancy" c. "Perhaps you should see a counselor to discuss these feelings" d. "I am quite concerned about these feelings. Could you explain more?"

d. Prepare the client for an emergency c-section

A nurse is caring for a client who is attempting a trial of labor (TOL) after several c-sections. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart tracing. Which of the following actions should the nurse take? a. Assist the client to the bathroom to empty her bladder b. Place the client in a knee-to-chest position c. Plan to administer calcium gluconate d. Prepare the client for an emergency c-section

d. Knock on the door and request permission to enter before approaching the client

A nurse is caring for a client who is blind in the left eye and visually impaired in the right eye. Which actions should the nurse employ to promote communication with this client? a. Touch the client's left arm before initiating a conversation b. Ensure that the door to the client's room is on the client's left side c. Close the window curtains and dim the lights before speaking with the client d. Knock on the door and request permission to enter before approaching the client

c. prepare equipment needed for newborn resuscitation **the nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse take? a. prepare the client for emergency c-section b. perform endotracheal suctioning as soon as the fetal head is delivered c. prepare equipment needed for newborn resuscitation d. prepare the client for an ultrasound exam

b. Counterpressure

A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation? a. Breathing techniques b. Counterpressure c. Biofeedback d. Use of a focal point

c. transition phase

A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore" Which of the following stages of labor is the client experiencing? a. second stage b. first stage c. transition phase d. latent phase

a. Moderate variability b. FHR accelerations d. Normal baseline FHR **moderate variability of 20/min (6-25 is expected for moderate variability), normal FHR baseline of 115-125/min, and accelerations are present with increases up to 150-150/min lasting for 25 seconds

A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes an FHR of 115 to 125/min with occasional increases up to 150 to 155/min that lasts for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following? (Select all that apply) a. Moderate variability b. FHR accelerations c. FHR decelerations d. Normal baseline FHR e. Fetal tachycardia

b. Reduced fetal oxygen supply

A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? a. Prolonged labor b. Reduced fetal oxygen supply c. Delayed cervical dilation d. Increased maternal stress

c. hypotension

A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block? a. nausea and vomiting b. tachycardia c. hypotension d. respiratory depression

c. Fetal asphyxia **oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? a. Diarrhea b. Thromboembolism c. Fetal asphyxia d. Oliguria

d. Evaluating the time from the beginning of the contraction to the beginning of the next contraction

A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions? a. Palpating the firmness of the uterus during a contraction b. Calculating the time from the end of each contraction to the beginning of the next c. Measuring the time from the beginning of a contraction to the end of that same contraction d. Evaluating the time from the beginning of the contraction to the beginning of the next contraction

d. "A distended bladder reduces pelvic space needed for birth" **reduces pelvic space, impedes fetal descent, and places the bladder at risk for trauma during the labor process

A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hours. Which of the following statements should the nurse make? a. "A full bladder increases the risk for fetal trauma" b. "A full bladder increases the risk for bladder infections" c. "A distended bladder will be traumatized by frequent pelvic exams" d. "A distended bladder reduces pelvic space needed for birth"

a. "Reduce the amount of food you eat during meals"

A nurse is caring for a client who is in the first trimester of pregnancy and asks how to manage heartburn. Which of the following responses should the nurse make? a. "Reduce the amount of food you eat during meals" b. "Sip carbonated beverages between meals" c. "Lie down and rest immediately after meals" d. "Drink iced tea with meals"

d. apply pressure to the client's sacral area during contractions **The nurse should provide counter pressure to the sacral area with a palm during contractions. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. What action should the nurse take? a. position the client supine with legs elevated b. instruct the client to pant during contractions c. encourage the client to soak in a warm bath d. apply pressure to the client's sacral area during contractions

b. Prepare for an impending delivery

A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? a. Assist the client to the bathroom b. Prepare for an impending delivery c. Prepare to remove a fecal impaction d. Encourage the client to take deep, cleansing breaths

c. Perform neurovascular checks of the extremities.

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative 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 exercises of the ankle and toes.

b. Provide a sitz bath with warm water for the client **Sitz bath can decrease episiostomy discomfort by providing warm, moist, and direct heat to the incision area

A nurse is caring for a client who is postpartum and reports her episiostomy incision is pulling and stinging. Which of the following actions should the nurse take? a. Encourage the client to ambulate b. Provide a sitz bath with warm water for the client c. Instruct the client to perform kegel exercises d. Apply anesthetic cream topically each hour while the client is awake

a. Increasing pulse and decreasing blood pressure

A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by postpartum hemorrhage? a. Increasing pulse and decreasing blood pressure b. Dizziness and increasing respiratory rate c. Cool, clammy skin and pale mucous membranes d. Altered mental status and level of consciousness

a. "You should eat some crackers before rising from bed in the morning" **Morning sickness is caused by the buildup of hCG in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client? a. "You should eat some crackers before rising from bed in the morning" b. "You should eat foods served at warm temperatures" c. "You should sip whole milk with breakfast" d. "You should brush your teeth immediately after meals"

a. Vaginal bleeding

A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following complications should the nurse include? a. Vaginal bleeding b. Swelling of the ankles c. Heartburn after eating d. Lightheadedness when lying on back

a. January 8

A nurse is caring for a client who is pregnant. and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? a. January 8 b. January 15 c. February 8 d. February 15

d. "You did great last time. Give it another try"

A nurse is caring for a client who is preparing to perform return demonstration of a subcutaneous injection of medication for the second time. The client hesitates and says, "I'm not sure I can do this". Which of the following responses should the nurse make? a. "Why are you so nervous? Do you need help?" b. "You need to talk to your doctor about prescribing an oral medication" c. "I know it's new. You'll get the hang of it soon" d. "You did great last time. Give it another try"

b. Edema at the infusion site **Edema d/t fluid entering subq tissue is an indication of infiltration; redness and warmth = phlebitis or infection; oozing = nonintact IV system

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? a. Redness at the infusion site b. Edema at the infusion site c. Warmth at the infusion site d. Oozing of blood at the infusion site

c. calcium gluconate

A nurse is caring for a client who is receiving mag sulfate by continuous IV. What meds should the nurse have available at bedside? a. naloxone b. protamine sulfate c. calcium gluconate d. atropine

c. "I should tell the nurse if the pain doesn't stop after I use this device"

A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? a. "I'll wait to use the device until it's absolutely necessary" b. "I'll be careful about pushing the button so I don't get an overdose" c. "I should tell the nurse if the pain doesn't stop after I use this device" d. "I will ask my son to push the dose button when I am sleeping"

c. The client will experience a successful induction of labor **a score of 8 or over favors a successful induction

A nurse is caring for a client who is schedule to receive IV Oxytocin for the induction of labor. The client has a Bishop score of 10. Which of the following should the nurse expect? a. The client will require medication for ripening of the cervix b. The client will experience lower back pain during labor c. The client will experience a successful induction of labor d. The client will require a vacuum or forceps assisted delivery

a. Offer to make arrangements for the Sacrament of the Sick

A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate? a. Offer to make arrangements for the Sacrament of the Sick b. Prepare to stay with the client's body until family arrives c. Arrange for a member of the client's family to bathe the body after death d. Post a sign on the client's door stating "No talking"

c. fundal consistency **Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? a. pulse rate b. blood pressure c. fundal consistency d. output

c. Manually apply upward pressure intravaginally on the presenting part **greatest risk to this client is fetal CNS injury or death from fetal hypoxia due to cord compression, so the first nursing action would be to take a gloved hand, insert into vagina, and apply upward pressure to the presenting part to move it away from the cord

A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first? a. Place the client in an extreme Trendelenburg position b. Increase the IV fluid infusion rate c. Manually apply upward pressure intravaginally on the presenting part d. Administer 8-10 L/min of oxygen

a. "You sound angry. Anger is a normal feeling associated with loss"

A nurse is caring for a client who lost a guardian to cancer last month. The client states, "I'd still have my guardian if the doctor would have made a diagnosis sooner". Which of the following responses should the nurse make? a. "You sound angry. Anger is a normal feeling associated with loss" b. "I think you would feel better if you talked about your feelings with a support group" c. "I understand just how you feel. I felt the same when my guardian died" d. "Do other members of your family also feel this way?"

d. assist the client to ambulate in the hallway

A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillow c. have the client drink fluids through a straw d. assist the client to ambulate in the hallway

c. Inform the client that this is an inappropriate statement

A nurse is caring for a client who states, "I would like to go out on a date with you". Which of the following is an appropriate response by the nurse? a. Ignore the client's behavior b. Suggest to the client that he spend time in his room c. Inform the client that this is an inappropriate statement d. Immediately leave the client's room

d. Weak pulse

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? a. Decreased heart rate b. Dyspnea c. Increased blood pressure d. Weak pulse

d. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution"

A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not acceptable treatment option. Which of the following responses should the nurse make? a. "I believe in this case you should really make an exception and accept the blood transfusion." b. " I know your family would approve of your decision to have a blood transfusion." c. "Why does your religion mandate that you cannot receive any blood transfusion?" d. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution"

b. "I need a second opinion. There is no lump"

A nurse is caring for a client who was just informed of a new diagnosis of breast cancer. The nurse evaluates the client's response. Which of the following statements by the client reflects a lack of understanding of an illness perspective? a. "I have no family history of breast cancer" b. "I need a second opinion. There is no lump" c. "I an glad we live in the city near several large hospitals" d. "I will schedule surgery next week, over the holidays"

b. april 15

A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule, the nurse should identify the client's estimated DOB as what? a. oct 15 b. april 15 c. oct 1 d. april 1

a. Turn the client onto her left side **Late decelerations indicate that the client is experiencing uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.

A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? a. Turn the client onto her left side b. Palpate the client's uterus c. Administer oxygen to the client d. Increase the client's IV fluids

b. The client has kept his partner's closet untouched since her death

A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief? a. The client joined a bowling league 2 months ago b. The client has kept his partner's closet untouched since her death c. The client exercises at a local health facility 3 days each week d. The client meets his daughter for dinner every week

b. "You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."

A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following is an appropriate response by the nurse? a. "It takes time to get over the loss of a loved one." b. "You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." c. "Why don't you try something to take your mind off your troubles, like watching a funny movie." d. "I might not share your exact situation, but I do know what people go through when they deal with a loss."

c. Keep familiar personal items at the bedside

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? a. Turn the television on at all times b. Hang abstract pictures on the walls c. Keep familiar personal items at the bedside d. Encourage bright glaring lighting in the room

b. A client attempts to climb out of bed and repeatedly states she must get home

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? a. A client wants to know the current time when there is a clock on the wall b. A client attempts to climb out of bed and repeatedly states she must get home c. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F) d. A client refuses to get out of bed and has no motivation to attend to daily hygiene

d. Minimal FHR variability and late decelerations

A nurse is caring for a laboring client who just received systemic medication for labor pain. Which fetal heart rate pattern would require further action by the nurse? a. Increased fetal heart rate (FHR) variability and early decelerations b. Moderate variability is present c. Occasional variable decelerations d. Minimal FHR variability and late decelerations

b. Genetic predisposition c. Hypertension d. Age e. Diabetes mellitus

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply) a. Sex b. Genetic predisposition c. Hypertension d. Age e. Diabetes mellitus

a. place the newborn directly on the client's chest

A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment

c. Continue to routinely monitor the newborn **This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

A nurse is caring for a newborn who has irregular respirations of 52/minute with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? a. Administer oxygen b. Place the newborn in an isolette c. Continue to routinely monitor the newborn d. Assess the newborn's blood glucose

b. 1.8

A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh? a. 2.4 b. 1.8 c. 0.8 d. 3.6

a. Respiratory depression

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? a. Respiratory depression b. Hypothermia c. Hypoglycemia d. Jaundice

b. Attempts to place their hands in their mouth

A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? a. Spits up clear mucus b. Attempts to place their hands in their mouth c. Turns the head toward sounds d. Lies quietly with their eyes open

b. Identify the client's pain level and medicate if needed

A nurse is caring for a patient who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is scheduled for physical therapy at 0900. Which of the following interventions should the nurse take? a. Encourage the client to use full weight bearing b. Identify the client's pain level and medicate if needed c. Teach the client which positions to avoid during PT d. Perform the client's morning care

a. fatigue b. insomnia d. flat affect

A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? (Select all that apply) a. fatigue b. insomnia c. euphoria d. flat affect e. delusions

c. determine the client's health risks

A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? a. give the client information about the immunization against meningitis b. tell the client to have a TB skin test every 2 years c. determine the client's health risks d. teach the client about exercise recommendations

b. Repeat the most important information. c. Practice empathetic skills. d. Be aware of nonverbal messages.

A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? (Select all that apply.) a. State goals of the session for the patient. b. Repeat the most important information. c. Practice empathetic skills. d. Be aware of nonverbal messages. e. Use a standard question list for the chosen topic.

a. "This is a normal, expected reaction for a child of this age"

A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before". Which of the following statements should the nurse make? a. "This is a normal, expected reaction for a child of this age" b. "This is a response to an overstimulating environment" c. "This is a common reaction to an overexposure to caregivers" d. "This is a typical reaction for a child who is sick"

d. "What worries you about being without your teeth?"

A nurse is caring for an older adult client who becomes agitated when the nurse requests that he remove his dentures prior to the beginning of surgery. Which of the following responses should the nurse provide? a. "It's for your safety. Dentures can slip and block your airway during surgery" b. "You would not want your teeth to be lost or broken during surgery, would you?" c. "The anesthesiologist requires all clients to remove their dentures" d. "What worries you about being without your teeth?"

b. open-angle glaucoma

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following disease? a. cataracts b. open-angle glaucoma c. macular degeneration d. angle-closure glaucoma

a. "This must be a difficult time for you"

A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life". Which of the following responses is appropriate? a. "This must be a difficult time for you" b. "Now she is no longer suffering" c. "I felt the exact same when my husband died" d. "You will feel better eventually"

a. "This must be a difficult time for you"

A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life". Which of the following responses is appropriate? a. "This must be a difficult time for you" b. "Now she is no longer suffering" c. "I felt the exact same when my husband died" d. "You will feel better eventually"

a. Betamethasone **because delivery is anticipated

A nurse is caring for client who is at 32 weeks of gestation and has placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider to prescribe? a. Betamethasone b. Indomethacin c. Nifedipine d. Methylergonovine

a. A newborn who is large for gestational age **One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia.

A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia? a. A newborn who is large for gestational age b. A newborn who has an Rh incompatibility c. A newborn who has pathologic jaundice d. A newborn who has fetal alcohol syndrome

c. The same religious beliefs can influence individuals differently

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these patients? a. Members of the same religion share similar feelings about their religion b. A shared religious background generates mutual regard for one another c. The same religious beliefs can influence individuals differently d. The nurse and client should discuss the differences and commonalities in their beliefs

a. 3 years old

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages? a. 3 years old b. 4 years old c. 5 years old d. 6 years old

b. 6 months **double by 6 months, triple by 12 months

A nurse is collecting data from an infant at a well-child visit. The nurse should understand that the birth weight typically doubles by what age? a. 3 months b. 6 months c. 9 months d. 12 months

a. offering advice

A nurse is communicating with a client who was admitted for a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? a. offering advice b. reflecting c. listening attentively d. giving information

b. Therapeutic communication builds a relationship that will allow expression of mutual concerns

A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse's purpose for using therapeutic communication with the client? a. Therapeutic communication identifies and analyzes the client's problem b. Therapeutic communication builds a relationship that will allow expression of mutual concerns c. Therapeutic communication provides a basis for the client's relationship with the provider d. Therapeutic communication ensures the client will remain cooperative with his care in the facility

c. Apnea for 10-second periods d. Obligatory nose breathing

A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply) a.Expiratory grunting b. Inspiratory nasal flaring c. Apnea for 10-second periods d. Obligatory nose breathing e. Crackles and wheezing

a. pain

A nurse is completing discharge teaching with client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? a. pain b. hearing loss c. client's culture d. motor impairment

b. "Inspect your incision daily for indications of infection" c. "Apply ice packs to the area for the first 24 hours"

A nurse is completing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (Select all that apply) a. "Avoid damage or moisture to the cast on your arm" b. "Inspect your incision daily for indications of infection" c. "Apply ice packs to the area for the first 24 hours" d. "Keep your arm in a dependent position"

b. "Are you having trouble carrying on with your normal activities?"

A nurse is conducting a grief and loss assessment interview and understands that the current loss, the history of previous losses, and lifestyle are all a part of this assessment. What question will the nurse ask the client to assess the current loss? a. "Do you drink on a regular basis?" b. "Are you having trouble carrying on with your normal activities?" c. "What types of coping mechanisms have you employed to work through your grief? d. "Do you have an active support system?"

a. "Apply cold compresses between feedings"

A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? a. "Apply cold compresses between feedings" b. "Take a warm shower right after feedings" c. "Apply breast milk to the nipples and allow them to air dry" d. "Use the various infant positions for feedings"

a. Client's level of comfort and ability to participate in the interview

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? a. Client's level of comfort and ability to participate in the interview b. Previous illnesses and surgeries c. Event's surrounding the client's recent illness d. Sociocultural history

a. "Would you like me to contact the chaplain to come speak with you?" d. "You know, it is quite normal to feel anger toward your husband at this time." e. "Tell me more about how you are feeling."

A nurse is consoling the partner of a client who just expired after along battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.) a. "Would you like me to contact the chaplain to come speak with you?" b. "You will feel better soon. You have been expecting this for a while now." c. "Let's talk about your children and how they are going to react." d. "You know, it is quite normal to feel anger toward your husband at this time." e. "Tell me more about how you are feeling."

c. "I will begin upon the client's admission to the facility"

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? a. "I will begin 48 hrs before the client's discharge" b. "I will begin once the client's discharge order is written" c. "I will begin upon the client's admission to the facility" d. "I will begin once the client's insurance company approves discharge coverage"

b. Two umbilical arteries and one umbilical vein.

A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of: a. Two umbilical veins and one umbilical artery. b. Two umbilical arteries and one umbilical vein. c. Arteries carrying oxygenated blood to the fetus. d. Veins carrying deoxygenated blood to the fetus.

c. Remove all clothing from the newborn except the diaper

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? a. Feed the newborn 1 oz of water every 4 hr b. Apply lotion to the newborn's skin 3x per day c. Remove all clothing from the newborn except the diaper d. Discontinue therapy if the newborn develops a rash

a. Encouraging the client to state the problems she is having

A nurse is developing a therapeutic relationship with a client who reports depression. Which of the following activities should the nurse initiate during the orientation phase of the therapeutic relationship? a. Encouraging the client to state the problems she is having b. Talking about alternative behavioral approaches the client could try c. Identifying assumptions that keep the client from reaching her potential d. Planning the incorporation of new strategies into the client's daily life

b. Decreased immune system c. Increased blood pressure e. Unhappiness

A nurse is discussing acute vs prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply) a. Chronic pain b. Decreased immune system c. Increased blood pressure d. Panic attacks e. Unhappiness

a. "I may experience feelings of resentment" b. "I will probably withdraw from others" c. "I can expect to experience changes in sleep"

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply) a. "I may experience feelings of resentment" b. "I will probably withdraw from others" c. "I can expect to experience changes in sleep" d. "It is possible that I will experience suicidal thoughts" e. "It is expected that I will have a loss of self-esteem"

d. Pain is whatever the client says it is

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? a. Most clients exaggerate their level of pain b. Pain must have an identifiable source to justify the use of opioids c. Objective data are essential in assessing pain d. Pain is whatever the client says it is

b. Hypoglycemia

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? a. Tachycardia b. Hypoglycemia c. Flushed skin d. Generalized petechiae

c. growth differences between girls and boys become evident

A nurse is discussing prepubescence and preadolescence with a group of guardians of school-age children. Which of the following information should the nurse include in the discussion? a. initial physiologic changes appear during early childhood b. changes in height and weight occur slowly during this period c. growth differences between girls and boys become evident d. sexual maturation becomes highly visible in boys

c. Persistent vomiting **Fetal movement is not expected during the 1st trimester. Quickening is the first perception of fetal movement, and occurs starting at 14-16 weeks gestation. Persistent vomiting can lead to hyperemesis gravidarum

A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client report to the provider during the first trimester? a. Breast tenderness b. Urinary frequency c. Persistent vomiting d. No fetal movement

b. "I will ask the client if they want to schedule some times to pray during the day"

A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements from the nurse indicates culturally responsive care to the client? a. "I will make sure the menu includes kosher options" b. "I will ask the client if they want to schedule some times to pray during the day" c. "I will avoid discussing care when the client's family is around" d. "I will make sure daily communion is available for this client"

b. Sharing computer passwords with coworkers

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? a. Logging out of the computer before leaving a terminal. b. Sharing computer passwords with coworkers c. Using a computer terminal in a non-public area. d. Preventing an unidentified health care worker from viewing a health record on the computer screen.

a. smoking on special occasions b. BMI of 28 e. history of reflux

A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable? (Select all that apply) a. smoking on special occasions b. BMI of 28 c. alopecia d. trisomy 21 e. history of reflux

a. "I have my health when I am physically, mentally, and socially well" b. "Health means wholeness, so every aspect of me combines to make a whole, healthy self" d. "Health means I do the things that keep me at my best, like exercising and eating right"

A nurse is giving a series of workshops about health and wellness to a group of older adults at a community center. Which of the following statements from the attendees demonstrate that they understood what the nurse explained about the concept of health? (Select all that apply) a. "I have my health when I am physically, mentally, and socially well" b. "Health means wholeness, so every aspect of me combines to make a whole, healthy self" c. "I am healthy because I see my doctor on a regular basis and he knows what I need" d. "Health means I do the things that keep me at my best, like exercising and eating right" e. "I don't have any medical problems right now, so I guess I'm pretty healthy"

d. When latched on, the infant's nose, cheek, and chin are touching the breast

A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicates understanding of the teaching? a. The parent places a few drops of water on their nipples before feeding b. The parent gently removes their nipple from the infant's mouth to break the suction c. When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger d. When latched on, the infant's nose, cheek, and chin are touching the breast

d. Contact the provider to clarify the prescription.

A nurse is having a difficulty reading the provider's writing when transcribing a prescription for a client's medication. Which of the following actions should the nurse take? a. Clarify the type of medication with the family. b. Review the medication history on the admission record. c. Send the prescription to the pharmacist to clarify. d. Contact the provider to clarify the prescription.

a. education c. gender d. perception

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply) a. education b. feedback c. gender d. perception e. time

a. Remove the sleeve of the gown from the arm without the IV line

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? a. Remove the sleeve of the gown from the arm without the IV line b. Slow the infusion using the roller clamp c. Disconnect the IV line from the pump d. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

a. Use of silence

A nurse is implementing therapeutic communication techniques with a client in an outpatient mental health facility. Which of the following actions allows the client an opportunity to organize thoughts, consider a topic, or think through a point? a. Use of silence b. Offering self c. Reflection of feelings d. Maintaining eye contact

b. the client accuses the nurse of being controlling just like their ex-partner

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? a. the client asks the nurse if they will go out to dinner together b. the client accuses the nurse of being controlling just like their ex-partner c. the client reminds the nurse of a friend who died from substance toxicity d. the client becomes angry and threatens to engage in self-harm

c. The partner has lost 20 lbs in the past 2 months

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? a. The partner has placed locks at the top of the doors leading to the outside b. The partner has hired a house cleaner c. The partner has lost 20 lbs in the past 2 months d. The partner redirects the client when the client is frustrated

a. Remove floor rugs c. Provide increased lighting in stairwells d. Install handrails in the bathroom e. Place the mattress on the floor

A nurse is making a home visit to a client who has Alzheimer's. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (Select all that apply) a. Remove floor rugs b. Have door locks that can be easily opened c. Provide increased lighting in stairwells d. Install handrails in the bathroom e. Place the mattress on the floor

d. Notify the physician or nurse-midwife.

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? a. Encourage the client's coach to continue to encourage breathing exercises. b. Encourage the client to continue pushing with each contraction. c. Continue monitoring the fetal heart rate. d. Notify the physician or nurse-midwife.

b. Variable decelerations

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? a. Early decelerations b. Variable decelerations c. Late decelerations d. Short-term variability

a. Restlessness b. Grimacing d. Clenching

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply) a. Restlessness b. Grimacing c. Moaning d. Clenching e. Drowsiness

c. Bradypnea d. Orthostatic hypotension e. Nausea

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply) a. Urinary incontinence b. Diarrhea c. Bradypnea d. Orthostatic hypotension e. Nausea

b. An increase in the pulse from 88 to 102 BPM. **rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume.

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? a. A temperature of 100.4°F. b. An increase in the pulse from 88 to 102 BPM. c. An increase in the respiratory rate from 18 to 22 breaths per minute. d. Blood pressure changes from 130/88 to 124/80 mm Hg.

b. the client is able to demonstrate the appropriate technique

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. the client is able to discuss the appropriate techniques b. the client is able to demonstrate the appropriate technique c. the client states an understanding of the process d. the client is able to write the steps on a piece of paper

d. "Do you have the same manifestations each time the headache occurs?"

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine headaches? a. "Do the headaches occur multiple times each day?" b. "Is your headache accompanied by profuse facial sweating?" c. "Does your headache occur on one side of your head?" d. "Do you have the same manifestations each time the headache occurs?"

c. Place a disposable covering on the scale d. Measure the infant from the crown of the head to the heels of the feet e. Balance the scale to 0 prior to use

A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply) a. Weigh the infant in a diaper b. Use a stadiometer to measure the infant c. Place a disposable covering on the scale d. Measure the infant from the crown of the head to the heels of the feet e. Balance the scale to 0 prior to use

b. Palpate the fundus of the uterus

A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? a. Apply palms of both hands to sides of uterus b. Palpate the fundus of the uterus c. Grasp lower uterine segment between thumb and fingers d. Stand facing client's feet with fingertips outlining cephalic prominence

a. grasp a rattle by the handle c. use a crude pincer grasp

A nurse is performing a developmental screening on a 10-month-old. Which of the following fine motor skills should the nurse expect the infant to perform? (Select all that apply) a. grasp a rattle by the handle b. try building a two-block tower c. use a crude pincer grasp d. place objects into a container e. walks with one hand held

a. ride a tricycle

A nurse is performing a developmental screening on a 3-year-old child. Which of the following skills should the nurse expect the child to perform? a. ride a tricycle b. hop on one foot c. jump rope d. throw a ball overhead

b. throw a ball overhead e. use a spoon without rotation

A nurse is performing a developmental screening on an 18 month old. Which of the following skills should the toddler be able to perform? (Select all that apply) a. build a tower with six blocks b. throw a ball overhead c. walk up and down stairs d. stand on one foot for a few seconds e. use a spoon without rotation

a. Demonstrate hearing aid battery replacement. b. Review method to check volume on hearing aid. d. Discuss the importance of having wax buildup in the ear canal removed.

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." After determining that the patient's hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? (Select all that apply) a. Demonstrate hearing aid battery replacement. b. Review method to check volume on hearing aid. c. Demonstrate how to wash the ear-mold and microphone with hot water. d. Discuss the importance of having wax buildup in the ear canal removed. e. Recommend a chemical cleaner to remove difficult buildup.

d. "What is your source of strength and hope?"

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? a. "When did you start to believe in your faith?" b. "How often do you perform religious rituals?" c. "Which church do you regularly attend?" d. "What is your source of strength and hope?"

b. Family report of personality changes c. Hallucinations e. Restlessness

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply) a. History of gradual memory loss b. Family report of personality changes c. Hallucinations d. Unaltered level of consciouness e. Restlessness

d. FHR is 90/min **fetal bradycardia indicates that this client is at greatest risk for fetal consequences

A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as a priority? a. Client reports a pain level of 8 on a scale from 0 to 10 during contractions b. The client's blood pressure is 148/92 mmHg c. The client's temperature is 38.3°C (101°F) d. FHR is 90/min

c. "How can I and the other nurses help you maintain your spiritual practices?"

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question to assess for spiritual needs? a. "Can you describe your usual spiritual practices and how you maintain them daily?" b. "Are your spiritual beliefs causing you any concern?" c. "How can I and the other nurses help you maintain your spiritual practices?" d. "How do your religious beliefs help you to feel at peace?"

b. Position the client prone several times each day

A nurse is planning a plan of care to prevent a client from developing flexion contractures following a below-the-knee amputation 24h ago. Which of the following actions should the nurse include in the plan of care? a. Limit any type of exercise to the residual limb for the first 48 hours after surgery b. Position the client prone several times each day c. Wrap the stump in a figure-eight pattern d. Encourage sitting in a chair during the day

a. assembling puzzles c. using musical toys d. playing with puppets e. coloring with crayons

A nurse is planning activities for preschoolers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply) a. assembling puzzles b. pulling wheeled toys c. using musical toys d. playing with puppets e. coloring with crayons

a. building models b. playing video games c. reading books e. playing board games

A nurse is planning activities for school-age children on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply) a. building models b. playing video games c. reading books d. using toy carpentry tools e. playing board games

c. filling and emptying containers d. playing with blocks e. looking at books

A nurse is planning activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply) a. building models b. working with clay c. filling and emptying containers d. playing with blocks e. looking at books

b. Place the client on contact precautions

A nurse is planning care for a client who has manifestations of a C. diff infection. Which of the following actions should the nurse plan to take? a. Place a surgical mask on the client during transport b. Place the client on contact precautions c. Use an alcohol-based agent to perform hand hygiene when caring for the client d. Obtain a blood specimen to test for C. diff

c. Group B streptococcus B-hemolytic **Obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection.

A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? a. Rubella titer b. Blood type c. Group B streptococcus B-hemolytic d. 1-hour glucose tolerance test

a. Assess color and temperature of the extremity c. Place pillows under the extremity d. Administer analgesic medication e. Assess pulse and sensation in the foot

A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following actions should the nurse take? (Select all that apply) a. Assess color and temperature of the extremity b. Apply warm compresses to incision sites c. Place pillows under the extremity d. Administer analgesic medication e. Assess pulse and sensation in the foot

d. at 28 weeks of gestation

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Globulin? a. while the client is in labor b. following an episode of influenza during pregnancy c. prior to a blood transfusion d. at 28 weeks of gestation

d. Use a small-gauge catheter when initiating IV therapy **use smallest gauge catheter possible to prevent irritation of the vein --> use a warm compress to TREAT phlebitis, not prevent it

A nurse is planning care for a client who is receiving IV therapy. Which of the following measures should the nurse include to prevent phlebitis? a. Change the IV site weekly b. Apply warm compress to IV site c. Use clean technique when replacing the transparent dressing over the IV site d. Use a small-gauge catheter when initiating IV therapy

b. Monitor the client's pedal pulses every hour. **to check for compartment syndrome

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? a. Instruct the client to flex and extend the ankle twice daily. b. Monitor the client's pedal pulses every hour. c. Remove the weights every four hours. d. Evaluate pressure points daily.

b. Prevent hip flexion of the affected extremity

A nurse is planning care for a postoperative client who is following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care? a. Instruct the client to avoid movement of the affected leg b. Prevent hip flexion of the affected extremity c. Position the lower extremities so that they are touching d. Ensure that the client's heels are touching the bed

a. Use a transfer device to lift the client up in bed

A nurse is planning care for an older adult who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Use a transfer device to lift the client up in bed b. Apply cornstarch to keep sensitive skin areas dry c. Massage the skin over the bony prominence d. Elevate the head of the bed no more than 45 degrees

a. discussing ways to use new behaviors

A nurse is planning care for the termination phase of a nurse-patient relationship. Which of the following actions should the nurse include in the plan of care? a. discussing ways to use new behaviors b. practicing new problem-solving skills c. developing goals d. establishing boundaries

a. Clean the incision daily with soap and water c. Sit in a straight-backed armchair e. Use a raised toilet seat.

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply) a. Clean the incision daily with soap and water b. Turn the toes inward when sitting or lying c. Sit in a straight-backed armchair d. Bend at the waist when putting on socks e. Use a raised toilet seat.

a. help the client see the benefits of their actions b. identify the client's support system c. suggest and recommend community resources e. teach stress management techniques **choice D is incorrect because the nurse and patient must work together to set goals, not have the nurse set them for the patient

A nurse is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply) a. help the client see the benefits of their actions b. identify the client's support system c. suggest and recommend community resources d. devise and set goals for the client e. teach stress management techniques

a. Wrap the stump with an elastic bandage in a figure-eight configuration.

A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take? a. Wrap the stump with an elastic bandage in a figure-eight configuration. b. Remove the elastic bandage and re-wrap the stump once per day. c. Perform passive range-of-motion exercises once daily. d. Secure the elastic bandage to the lowest joint.

a. toddlers depend on their senses to learn **​Toddlers are in the sensorimotor cognitive stage, which means that they learn through their senses.

A nurse is preparing a toddler for surgery. Which of the following is appropriate for the nurse to take into consideration when developing the teaching plan? a. toddlers depend on their senses to learn b. toddlers view their illness as a punishment c. toddlers see themselves as individuals

a. Excessive stressors cause the client to experience distress

A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion? a. Excessive stressors cause the client to experience distress b. The body's initial adaptive response to stress is denial c. Absence of stressors results in homeostasis d. Negative, rather than positive, stressors produce a biological response

d. determine what the client knows about stress incontinence

A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the take first when meeting with the client? a. encourage the client to actively listen during the session b. select instructional materials c. identify goals the nurse and client agree are reasonable d. determine what the client knows about stress incontinence

a. Check the client's medical record for the provider's prescription.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? a. Check the client's medical record for the provider's prescription. b. Explain to the client that the provider prescribed the procedure. c. Assure the client that enemas are commonly prescribed for constipation. d. Inform the charge nurse that the client refused the enema.

a. 0.25

A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer? a. 0.25 b. 25 c. 50 d. 0.50

a. IV narcotics administered to the mother during labor

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? a. IV narcotics administered to the mother during labor b. Maternal drug use c. Hyaline membrane disease d. Meconium aspiration

d. Place the newborn skin to skin on the mother's chest **Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety.

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? a. Apply a cool pack for 10 min to heel prior to the puncture b. Request a prescription for IM analgesic c. Use a manual lance blade to pierce the skin d. Place the newborn skin to skin on the mother's chest

a. Client's cognitive ability b. Client's current physical needs c. Client's level of motivation d. Client's developmental stage

A nurse is preparing to teach a client how to ambulate with crutches and is determining a client's readiness to learn. Which of the following factors should the nurse include in this assessment? (Select all that apply) a. Client's cognitive ability b. Client's current physical needs c. Client's level of motivation d. Client's developmental stage e. Client's preferred learning style

c. Set mutual goals for the education session.

A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? a. Allow patient to manipulate machine and look at parts. b. Provide a teach-back session. c. Set mutual goals for the education session. d. Discuss the purpose of the machine and how it works.

c. Give a written summary of the client's nursing plan of care to the long-term care facility

A nurse is preparing to transfer an older adult client to a long-term care facility. To promote continuity of care, which of the following actions should the nurse take? a. Discuss the client's long-term recovery goals with him b. Discuss the client's nursing care needs with the provider c. Give a written summary of the client's nursing plan of care to the long-term care facility d. Review the client's nursing care plan with his family members

a. Higher than the primary bag

A nurse is preparing to use the piggyback method to administer a secondary IV medication. Where should the nurse place the secondary bag? a. Higher than the primary bag b. Lower than the primary bag c. Equal in height to the primary bag d. Retrieve a different pump for the bag

c. separates easily from primary care giver for short periods of time

A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of the toddler? a. explains the difference between right and wrong b. prints letters and numbers c. separates easily from primary care giver for short periods of time d. cooperative in doing simple chores

a. develop food habits that will prevent dental caries c. expression of bedtime fears is common d. expect behaviors associated with negativisim and ritualism

A nurse is providing anticipatory guidance to the caregivers of a toddler. Which of the following should the nurse include? (Select all that apply) a. develop food habits that will prevent dental caries b. meeting caloric needs results in an increased appetite c. expression of bedtime fears is common d. expect behaviors associated with negativism and ritualism

a. Continue to monitor the fetal heart tracings **Early decels reflect fetal head compression and are a normal finding during labor

A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take? a. Continue to monitor the fetal heart tracings b. Elevate the client's legs c. Increase the rate of the maintenance IV fluid d. Administer oxygen

d. Offer the mother private time with the newborn

A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first? a. Assist the client with transferring to the gynecology unit b. Administer Alprazolam 0.5 mg PO c. Contact the health care facility's clergy d. Offer the mother private time with the newborn

b. A client who does not wash their hands between perineal care and breastfeeding

A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? a. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration b. A client who does not wash their hands between perineal care and breastfeeding c. A client who is not breastfeeding and is using measures to prevent lactation d. A client who has a c-section incision that is well-approximated with no drainage

d. "Apply a cool cloth to the face during a headache"

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? a. "Use music therapy for relaxation with the onset of a headache" b. "Increase physical activity when a headache is present" c. "Drink beverages that contain artificial sweeteners to prevent headaches" d. "Apply a cool cloth to the face during a headache"

b. Talk to the client as if he is an adult c. Provide time to teach the client privately d. Use audiovisuals as a teaching tool

A nurse is providing discharge teaching for an adolescent client. Which of the following teaching strategies is appropriate for the nurse to use when teaching this client? (Select all that apply) a. Focus teaching toward the client's parents b. Talk to the client as if he is an adult c. Provide time to teach the client privately d. Use audiovisuals as a teaching tool e. Use reminiscence when discussing information

b. A straight-backed chair with an elevated seat

A nurse is providing discharge teaching to a client following hip arthroplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home? a. A reclining chair with an ottoman b. A straight-backed chair with an elevated seat c. A couch with plush cushions d. A rocking chair with a curved back

b. Adjust the thermostat so that the environment is warm **The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? a. Apply a heating pad on a low setting to help relieve leg pain b. Adjust the thermostat so that the environment is warm c. Wear antiembolic stockings during the day d. Rest with the legs above the heart

c. Obtain a gift from the newborn to present to the sibling

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? a. Allow the sibling to hold the newborn during a bath b. Make sure the sibling kisses the newborn each night c. Obtain a gift from the newborn to present to the sibling d. Switch the sibling's room with the nursery

c. Progesterone **Progesterone maintains the endometrium and has a relaxant effect on the uterus so the fetus is not expelled

A nurse is providing education for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage? a. Oxytocin b. Prolactin c. Progesterone d. Estrogen

a. "Without treatment, glaucoma can cause blindness"

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? a. "Without treatment, glaucoma can cause blindness" b. "Double vision is a common symptom of glaucoma" c. "Glaucoma is caused by inadequate production of fluid within the eye" d. "Use of eye drops will improve vision over time"

a. management of tantrums d. dental care

A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply) a. management of tantrums b. how to establish trust c. how to encourage cooperative play d. dental care e. need for increased caloric intake

a. Apply heat to joints to alleviate pain b. Ice inflamed joints following activity c. Install an elevated toilet seat

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information (Select all that apply) a. Apply heat to joints to alleviate pain b. Ice inflamed joints following activity c. Install an elevated toilet seat d. Take tub baths

c. "I will discard any unused breastmilk that is left in the bottle" **bacteria can grow in breastmilk

A nurse is providing postpartum discharge teaching about the proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? a. "I can store my pumped milk in the door of the refrigerator" b. "I can use the microwave to thaw my frozen breast milk" c. "I will discard any unused breastmilk that is left in the bottle" d. "I can refreeze any breastmilk after is has been thawed"

c. "Can you tell me about how long the surgery will take?"

A nurse is providing preoperative education for a client who will undergo a mastectomy. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I don't want my spouse to see my incision" b. "Will you give me pain medicine after the surgery?" c. "Can you tell me about how long the surgery will take?" d. "My roommate listens to everything I say"

b. "I should clean my baby's teeth with a cool, wet wash cloth"

A nurse is providing teaching about dental care and teething to the caregiver of a 9-month-old infant. Which of the following statements by the caregiver indicates an understanding of the teaching? a. "I can give my baby a warm teething ring to relieve discomfort" b. "I should clean my baby's teeth with a cool, wet wash cloth" c. "I can give Advil for up to 5 days while my baby is teething" d. "I should place diluted juice in the bottle my baby drinks while falling asleep"

a. Cold cabbage leaves **fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement.

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? a. Cold cabbage leaves b. Purified lanolin cream c. A snug-fitting support bra d. Breast shells

b. Check the expiration dates on food

A nurse is providing teaching for a client diagnosed with an olfactory deficit. Which interventions specifically related to an olfactory deficit will the nurse include in the​ teaching? a. Set up a schedule for changing the batteries in carbon monoxide detectors b. Check the expiration dates on food c. Recommend the client purchase smoke detectors with flashing lights d. Darken the rooms with shades

c. "Your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery"

A nurse is providing teaching for a client postpartum who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? a. "You should supplement your baby with formula until you notice that your breasts become firm and full" b. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat" c. "Your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery" d. "It is typical for your nipples to hurt for the first few weeks while you are breastfeeding"

a. "I should feed my baby 8-12 times a day, based on feeding cues"

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? a. "I should feed my baby 8-12 times a day, based on feeding cues" b. "My baby should have 6 or 7 wet diapers a day during the first week" c. "I should switch my baby to the other breast after 15 minutes of feeding" d. "My nipple pain should go away after a few weeks of breastfeeding"

a. "I will need to wipe my perineal area from back to front after urination"

A nurse is providing teaching to a client about measures to prevent urinary tract infections. Which of the following client statements indicates a need for further teaching? a. "I will need to wipe my perineal area from back to front after urination" b. "I will need to empty my bladder regularly and completely" c. "I will need to drink apple cider vinegar each day" d. "I need to drink 8 cups of liquid each day"

c. "Low-impact aerobic exercises can help reduce episodes of pain"

A nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates an understanding of the teaching? a. "I should increase my caffeine intake" b. "I will take my Duloxetine in the morning so I have more energy to accomplish tasks" c. "Low-impact aerobic exercises can help reduce episodes of pain" d. "A course of chemotherapy treatment should provide a cure"

c. it is normal for my baby to sometimes feed every hr for several hours in a row **The mother should follow her newborn's cues and feed her 8-12 times per day

A nurse is providing teaching to a client who is planning to breastfeed her newborn. What statement by the client indicates an understanding of the teaching? a. I must drink milk every day in order to assure good quality breast milk b. drinking lots of fluids will increase my breast milk production c. it is normal for my baby to sometimes feed every hr for several hours in a row d. after the first few weeks, my nipples will toughen up and breastfeeding wont hurt anymore

b. place ice packs on your breasts

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? a. stand under hot shower with your breasts exposed b. place ice packs on your breasts c. limit fluid intake to 1 L per day d. wear a loose-fitting, comfortable bra

d. Limit choices offered to the client **Choices should be limited for the client to reduce confusion and frustration

A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease. Which of the following information should the nurse include in the teaching? a. Place abstract pictures on the wall in the client's room b. Provide music for the client using headphones c. Reorient the client to reality frequently d. Limit choices offered to the client

d. "I will keep a dim lamp on in my child's room during the night"

A nurse is providing teaching to the guardian of a preschool-age child about methods to promote sleep. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will sleep in the bed with my child if she wakes up during the night" b. "I will let my child stay up an additional 2 hours on weekend nights" c. "I will let my child watch television for 30 minutes just before bedtime each night" d. "I will keep a dim lamp on in my child's room during the night"

c. I will place my baby on his back when it is time for him to sleep

A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm

a. Gloves

A nurse is removing PPE after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? a. Gloves b. Gown c. Eyewear d. Mask

d. "I take the batteries out of my hearing aids when I take them off at night."

A nurse is reviewing instructions with a client who is hearing impaired and has just started wearing hearing aids. Which of the following statements by the client indicates understanding of the instructions? a. "I use a damp cloth to clean the outside part of my hearing aids." b. "I clean the ear molds of my hearing aids with rubbing alcohol." c. "I keep the volume of my hearing aids turned up so I can hear better." d. "I take the batteries out of my hearing aids when I take them off at night."

a. instruct the client to obtain a rubella immunization after delivery

A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type O neg. What action should the nurse take? a. instruct the client to obtain a rubella immunization after delivery b. request a script for an antibiotic until delivery c. inform the client that she will have to deliver via c-section d. administer a dose of Pho(D) immune globulin

d. relaxation between uterine contractions

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? a. peak of the uterine contraction b. moderate variability c. FHR acceleration d. relaxation between uterine contractions

a. Chadwick's sign c. Goodell's sign d. Positive pregnancy test

A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (Select all that apply) a. Chadwick's sign b. Quickening c. Goodell's sign d. Positive pregnancy test e. Frequent nausea and vomiting

b. perform a vaginal exam **when a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os. The nurse should clarify this prescription bc any manipulation can cause tearing of the placenta/increased bleeding.

A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta previa and bleeding. What scripts should the nurse clarify with the provider? a. insert a large-bore IV catheter b. perform a vaginal exam c. perform continuous external fetal monitoring d. obtain a blood sample for lab testing

a. Hemoglobin 10 g/dl **A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. WBC - finding is within the expected reference range of 5,000 to 15,000/mm3 Platelets - within the expected reference range of 150,000 to 400,000/mm3 FBG - within the expected reference range of 60 to 105 mg/dL

A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? a. Hemoglobin 10 g/dl b. WBC count 10,000/mm c. Platelets 250,000/mm d. Fasting blood glucose 90 mg/dl

b. Eating popcorn at the movie theater d. Consuming 36oz beer daily

A nurse is screening a client for hypertension. The nurse should identify that which of the following actions by the client increases the risk for hypertension? (Select all that apply) a. Drinking 8oz non-fat milk daily b. Eating popcorn at the movie theater c. Walking 1 mile daily at 12 min/mile pace d. Consuming 36oz beer daily e. Getting a massage 1x per week

b. Sudden confusion **Alzheimer's is gradual

A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's disease. The nurse should conclude that the group requires further teaching when a member identifies which of the following findings as a manifestation of Alzheimer's disease? a. Impaired judgment b. Sudden confusion c. Personality change d. Remote memory loss

b. "These feelings are common to expectant fathers in early pregnancy"

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? a. "Has your wife sensed your anger toward her and the baby?" b. "These feelings are common to expectant fathers in early pregnancy" c. "I'm sure that it's really hard to accept this when it's your baby, too" d. "It would be wise for you to speak to a therapist about these feelings"

d. "Have you experienced frequent, small liquid stools recently?"

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? a. "Have you eaten more high-fiber foods lately?" b. "Have you taken antibiotics recently?" c. "Do you have gluten intolerance?" d. "Have you experienced frequent, small liquid stools recently?"

c. "Losing someone close to you must be very upsetting"

A nurse is talking with a client who is at risk for suicide following their partner's death. Which of the following statements should the nurse make? a. "I feel very sorry for the loneliness you must be experiencing" b. "Suicide is not the appropriate way to cope with loss" c. "Losing someone close to you must be very upsetting" d. "I know how difficult it is to lose a loved one"

b. "My child has temper tantrums every time we tell them to do something they don't want to do"

A nurse is talking with guardians who are concerned about several issues with their preschooler. Which of the following issues should the nurse identify as the priority? a. "My child mimics the way my partner and I dress" b. "My child has temper tantrums every time we tell them to do something they don't want to do" c. "I think my child truly believes that toys have personalities and can talk" d. "I feel bad when I see my child trying so hard to button their shirt"

d. "I understand you're concerned. Let's discuss what concerns you specifically"

A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? a. "I think your child is getting better. What have you noticed?" b. "I'm sure everything will be okay. It just takes time to heal" c. "I'm not sure what is wrong. Have you asked the doctor about your concerns" d. "I understand you're concerned. Let's discuss what concerns you specifically"

a. Spirituality decreases feelings of depression

A nurse is teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include? a. Spirituality decreases feelings of depression b. Spirituality increases feelings of hopelessness c. Spirituality decreases quality of life d. Spirituality increases the desire to hasten death

b. performing monthly breast self exams

A nurse is teaching a class on health promotion and illness prevention. the nurse should include that which of the following is an example of secondary prevention? a. providing a community program on stress reduction b. performing monthly breast self exams c. teaching foot care to a client who has diabetes d. referring a client who has had a mastectomy to a support group

a. "This medication will prevent me from developing a blood​ clot."​

A nurse is teaching a client about aspirin for peripheral vascular disease​ (PVD). Which client statement indicates that teaching has been​ successful?​ a. "This medication will prevent me from developing a blood​ clot."​ b. "This medication will thin out my blood so it flows​ easier."​ c. "This medication will open my arteries and increase blood flow to my​ legs."​ d. "This medication will help decrease the plaque in my​ arteries."

c. Stress incontinence

A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? a. Urinary hesitancy b. Hematuria c. Stress incontinence d. Increased vaginal moisture

a. "Cognitive reframing will help me change my irrational thoughts to something positive"

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching? a. "Cognitive reframing will help me change my irrational thoughts to something positive" b. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate" c. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety" d. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety"

d. "How do you feel diabetes will affect your current lifestyle?"

A nurse is teaching a client who has a new diagnosis of diabetes type I. Which of the following questions by the nurse addresses the client's affective domain? a. "Are you ready to learn how to give yourself insulin injections?" b. "What information do you already know about diabetes?" c. "Have you ever seen anyone give themselves an insulin injection?" d. "How do you feel diabetes will affect your current lifestyle?"

d. Driving can be dangerous due to the loss of peripheral vision **Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated; Eye drops will not improve vision but they can reduce intraocular pressure and prevent further vision loss

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma. Which of the following information should the nurse include in the teaching? a. Lost vision can improve with eye drops b. Administer eye drops as needed for vision loss c. Glasses will be necessary to correct accompanying presbyopia d. Driving can be dangerous due to the loss of peripheral vision

d. Place both legs in dependent position when sleeping **will decrease swelling

A nurse is teaching a client who has a new diagnosis of severe PAD. Which of the following instructions should the nurse include? a. Wear tightly-fitted insulated socks with shoes when going outside b. Elevate both legs above the heart when resting c. Apply a heating pad to both legs for comfort d. Place both legs in dependent position when sleeping

b. "Use elastic stockings"

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include? a. "Apply ice packs to your legs" b. "Use elastic stockings" c. "Remain on bed rest" d. "Place your legs in a dependent position while in bed"

a. Excessive laxative use b. Ignoring the urge to defecate c. Inadequate fluid intake

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of the constipation? (Select all that apply) a. Excessive laxative use b. Ignoring the urge to defecate c. Inadequate fluid intake d. Increased fiber in diet e. Increased activity

b. feeling of warmth

A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. What adverse effects should the nurse include in the teaching? a. elevated BP b. feeling of warmth c. generalized pruritis d. hyperactivity

c. swelling of the face **can indicate a hypertensive disorder or preeclampsia.

A nurse is teaching a client who is at 12 wks gestation about manifestations of potential complications that she should report to her provider. What info should the nurse include in the teaching? a. intermittent nausea b. white vaginal discharge c. swelling of the face d. urinary frequency

c. vaginal bleeding **might indicate a complication such as placental abruption, placenta previa, or preterm labor. choice A is not right because the client should feel the fetus move at least 3 times per hour, so 10 is acceptable

A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. What finding should the nurse include in the teaching? a. 10 fetal movements per hour b. mild constipation c. vaginal bleeding d. nasal congestion

a. Breast tenderness b. Urinary frequency c. Epistaxis

A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (Select all that apply) a. Breast tenderness b. Urinary frequency c. Epistaxis d. Dysuria e. Epigastric pain

c. Use proper body mechanics

A nurse is teaching a group of clients who are pregnant about measures to relieve backache pain during pregnancy. Which of the following measures should the nurse include? a. Avoid any lifting b. Perform Kegel exercises twice a day c. Use proper body mechanics d. Avoid constrictive clothing

a. "Our car seat is rear-facing facing in the back seat."

A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? a. "Our car seat is rear-facing in the back seat." b. "Our car seat is front-facing in the back seat." c. "I can fit my hand between the baby and the car seat harness." d. "The car seat is rear-facing in the front passenger seat."

a. Speak in a low tone. b. Begin and end the session with the most important information regarding melanoma. d. Provide specific information in frequent, small amounts for older adult patients.

A nurse is teaching an older adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) a. Speak in a low tone. b. Begin and end the session with the most important information regarding melanoma. c. Provide a pamphlet about melanoma with large font in blues and greens. d. Provide specific information in frequent, small amounts for older adult patients. e. Speak quickly so that you do not take up much of the patient's time.

d. Feeling of fullness in the ear **A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

A nurse is teaching the client about otitis media. Which of the following manifestations should the nurse include in the teaching? a. A high-pitched sound heard in the ear b. Intermittent rapid eye movement c. Itching on the external canal d. Feeling of fullness in the ear

b. Determine client understanding several times during the conversation d. Use lay terms if possible. e. Do not interrupt the interpreter and the family as they talk

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply) a. Talk to the interpreter about the family while the family is in the room b. Determine client understanding several times during the conversation c. Look at the interpreter when asking the family questions d. Use lay terms if possible. e. Do not interrupt the interpreter and the family as they talk

d. use attentive listening with the client

A nurse is using communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take? a. focus on the client's present circumstances instead of personal stories b. verbalize understanding of how the client feels c. offer the client personal thoughts and beliefs d. use attentive listening with the client

a. Interpersonal relationships b. Culture d. Religious beliefs e. Prior experience with loss

A nurse is working with a client who recently lost a guardian. The nurse recognizes that which of the following factors influences a client's grief and coping ability? (Select all that apply) a. Interpersonal relationships b. Culture c. Birth order d. Religious beliefs e. Prior experience with loss

d. "A client should avoid consuming undercooked meat while pregnant"

A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? a. "Obtain an immunization against rubella early in pregnancy" b. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy" c. "A client should avoid crowded places during pregnancy" d. "A client should avoid consuming undercooked meat while pregnant"

d. Talk the client through tasks one step at a time

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? a. Rotate assignment of daily caregivers b. Provide an activity schedule that changes from day to day c. Limit time for the client to perform activities d. Talk the client through tasks one step at a time

b. Client who reports right calf pain and shortness of breath **risk of respiratory arrest due to an embolism

A nurse on a med-surg unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? a. Client who has a pressure injury of the right heel whose blood glucose is 300 mg/dL b. Client who reports right calf pain and shortness of breath c. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization d. Client who has dark red coloration of left toes and absent pedal pulse

b. A client who had premature rupture of membranes and prolonged labor

A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? a. A client who experienced a precipitous labor less than 3 hours in duration b. A client who had premature rupture of membranes and prolonged labor c. A client who delivered a large for gestational age infant d. A client who had a boggy uterus that was not well-contracted

b. Loss of central vision

A nurse performs an assessment of a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which of the following symptoms? a. Loss of peripheral vision b. Loss of central vision c. Cloudiness of the lens d. Sudden, severe pain

c. The nurse should select a chair or stool that positions the nurse at about the same level as the client.

A nurse plans to interview a hospitalized client who is lying supine with the head elevated at 45 degrees. Which initial action by the nurse will most enhance the probability of achieving a therapeutic interaction? a. The nurse should transfer the client to a chair near the door if the client is able to move. b. The nurse should stand during the interview to establish professional credibility. c. The nurse should select a chair or stool that positions the nurse at about the same level as the client. d. The nurse should maintain the room arrangement without alteration to enhance the client's comfort.

b. Contractions that last for 60 seconds each with a 3-min rest between contractions **A contraction interval is how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.

A nurse receives report on a client who is in labor and is experiencing contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. Contractions that last for 60 seconds each with a 4-min rest between contractions b. Contractions that last for 60 seconds each with a 3-min rest between contractions c. A contraction that lasts 4 min followed by a period of relaxation d. Contractions that last 45 seconds with a 3-min rest between contractions

d. request the client to rate the pain on a scale of 1 to 10

A nurse recently administered morphine sulfate IV (Roxanol) to a client. Which of the following is the best way to measure therapeutic effect? a. recheck the clients vital signs b. observe the client for facial grimacing c. ask the client if the pain is relieved d. request the client to rate the pain on a scale of 1 to 10

a. "As a nurse, I am required by law to report suspected child abuse."

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurses is appropriate? a. "As a nurse, I am required by law to report suspected child abuse." b. "I am unable to discuss this, but I can contact my supervisor to speak with you." c. "The provider will be coming to explain the situation." d. "I reported the incident to my supervisor who decided to contact the authorities."

b. Tell the nurse who sent the text that the text is a HIPAA violation. c. Inform the nursing supervisor.

A nurse sends a text message to the oncoming nurse to report that a patient refuses to take medication as ordered. What should the oncoming nurse do? (Select all that apply). a. Add this information to the board hanging at the patient's bedside. b. Tell the nurse who sent the text that the text is a HIPAA violation. c. Inform the nursing supervisor. d. Forward the text to the charge nurse. e. Thank the nurse for sending the information.

a. Ectopic pregnancy

A nurse that was just assigned to her patient on the OB floor notices a new prescription for Methotrexate. She recognizes that this medication is related to which pregnancy complication? a. Ectopic pregnancy b. Placenta previa c. Abruptio placentae d. Preterm labor

c. "Did either prayer or meditation prove helpful to you?"

A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? a. "Do you feel the need to forgive your wife over your loss?" b. "What can I do to help you feel more at peace?" c. "Did either prayer or meditation prove helpful to you?" d. "Should we plan on having your family try to visit you more often in the hospital?"

d. Unit manager

A nurse witnesses another nurse not working within the Standards of Practice. The nurse should report the incident to which of the following? a. Hospital ethics committee b. Quality improvement committee c. Clinical Education Specialist d. Unit manager

b. "I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?" d. "Describe for me what you do with your time when you are not working." e. "The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to e-mail the schedule to you?"

A nurse working on a medical patient care unit states, "I am having trouble sleeping, and I eat nonstop when I get home. All I can think of when I get to work is how I can't wait for my shift to be over. I wish I felt happy again." What are the best responses from the nurse manager? (Select all that apply) a. "I'm sure this is just a phase you are going through. Hang in there. You'll feel better soon." b. "I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?" c. "You can take diphenhydramine over the counter to help you sleep at night." d. "Describe for me what you do with your time when you are not working." e. "The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to e-mail the schedule to you?"

d. An older adult who has a hip fracture and is in Buck's traction

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? a. An adolescent who has cervical fractures and is in a halo brace b. A young adult who has a femur fracture and is in skeletal balanced suspension traction c. A middle adult who has a fractured radius and arm cast d. An older adult who has a hip fracture and is in Buck's traction

a. FSH and LH are released from the anterior pituitary gland.

A nursing instructor is conducting a lecture and is reviewing the functions of the female reproductive system. She asks the student nurse to describe the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH). The student nurse accurately responds by stating that: a. FSH and LH are released from the anterior pituitary gland. b. FSH and LH are secreted by the corpus luteum of the ovary c. FSH and LH are secreted by the adrenal glands d. FSH and LH stimulate the formation of milk during pregnancy.

c. Cognitive domain e. Psychomotor domain

A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? (Select all that apply.) a. Affective domain b. Sensory domain c. Cognitive domain d. Attentional domain e. Psychomotor domain

b. Phantom limb sensation

A patient complains that her amputated foot itches and feels hot. This represents which of the following? a. Poor psychological adjustment b. Phantom limb sensation c. Early symptoms of infection d. Denial of the amputation

c. Tertiary prevention

A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Transtheoretical prevention

d. Prolonged QT interval on the EKG **calcium has a lot of effects on the heart

A patient has a calcium level of 7.2 mg/dL. What sign below is indicative of this lab value? a. None, this is a normal calcium level b. Shortened ST segment c. Hypoactive bowel sounds d. Prolonged QT interval on the EKG

a. venous ulcer **the wet wound and drainage indicates a venous ulcer

A patient has an ulcer on the medial malleolus. The ulcer is shallow with irregular edges. The wound base is red. Wound drainage is also present. What type of ulcer is this based on the scenario's description? a. venous ulcer b. arterial ulcer c. diabetic ulcer

d. demonstration

A patient has been diagnosed with diabetes and must learn to give himself injections of insulin and perform blood glucose checks. Which of the following represents the best teaching method? a. group instruction b. simulation c. one on one discussion d. demonstration

a. Difficulty paying his bills e. Family practice of not routinely seeing a health care provider

A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary health care provider because he has never really been sick, and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) a. Difficulty paying his bills b. Praying daily c. Age of patient (46 years) d. Stress from the divorce and the loss of a job e. Family practice of not routinely seeing a health care provider

a. Teaching how activities such as reading and using crossword puzzles provide stimulation c. Turning on the lights and opening the room blinds d. Sitting down, speaking, touching, and listening to his feelings and perceptions

A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply) a. Teaching how activities such as reading and using crossword puzzles provide stimulation b. Moving him to a room away from the nurses' station c. Turning on the lights and opening the room blinds d. Sitting down, speaking, touching, and listening to his feelings and perceptions e. Providing auditory stimulation for the patient by keeping the television on continuously

b. Sit down and talk with the patient; have her discuss her feelings and listen attentively.

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? a. Make a referral to a professional spiritual care adviser. b. Sit down and talk with the patient; have her discuss her feelings and listen attentively. c. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. d. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

b. Application of compression stockings c. Limit long periods of standing and sitting **The patient with peripheral VENOUS disease should elevate the lower extremities ABOVE heart level (this helps return blood to the heart and decrease swelling/pain), avoid crossing the legs (or the knee-flexed position) because this impedes blood flow, and limit long periods of standing and sitting (this limits blood return to the heart and increases swelling)

A patient has severe peripheral venous disease. What important information below will the nurse provide to the patient about how to alleviate signs and symptoms associated with the disease? (Select all that apply) a. Elevate the lower extremities below heart level frequently b. Application of compression stockings c. Limit long periods of standing and sitting d. Use the knee-flexed position while lying in bed

c. Stool softeners

A patient is being discharged home on an around-the-clock (ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication? a. Opioid antagonists b. Antiemetics c. Stool softeners d. Muscle relaxants

c. A diagnosis of AD is made only after other causes of dementia are ruled out

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that.... a. The most important risk factor for AD is a family history of the disorder b. New drugs have been shown to reverse AD dramatically in some patients c. A diagnosis of AD is made only after other causes of dementia are ruled out d. The presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

a. Gravida 3, para 2

A patient is currently 32 weeks pregnant. She reports being pregnant 2 other times before this current pregnancy, and had 2 live births at 39 and 40 weeks. Which option below best describes the patient's gravidity and parity? a. Gravida 3, para 2 b. Gravida 2, para 3 c. Gravida 2, para 2 d. Gravida 4, para 2

c. Stress

A patient is experiencing which type of incontinence if she experiences leaking urine when she coughs, sneezes, or lifts heavy objects? a. Overflow b. Reflex c. Stress d. Urge

b. Big toe

A patient is post-op from surgery. The patient has a history of gout. While performing a head-to-toe assessment, you assess the patient for signs and symptoms of gout. As the nurse, you know that gout tends to start at what site? a. Elbow b. Big toe c. Thumb or index finger d. Knees

b. Diluted **always dilute IV potassium since it is so irritating to the skin/veins

A patient is receiving IV potassium supplements for his condition. How should the supplements be administered? a. Undiluted b. Diluted c. On an empty stomach d. At bedtime

d. Right Patient

A patient is scheduled to take three medications at 1000. The nurse confirms the following about each medication: right medication, right dose, right time, and right route. When thinking of the first 5 Rights of Medication Administration what "right" is the nurse missing?* a. Right Site b. Right Assessment c. Right Documentation d. Right Patient

b. psychomotor

A patient needs to learn to use a walker. This skill will require learning in which of the following domains? a. cognitive b. psychomotor c. attentional d. affective

c. Oral corticosteroids **Intra-articular corticosteroids (an injection in the joint) are commonly prescribed rather than oral corticosteroids

A patient newly diagnosed with osteoarthritis asks about the medication treatments for their condition. Which medication is NOT typically prescribed for osteoarthritis? a. NSAIDs b. Topical Creams c. Oral corticosteroids d. Acetaminophen (Tylenol)

b. Maintain a consistent daily routine for the patient's care

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past b. Maintain a consistent daily routine for the patient's care c. Reorient the patient to the date and time every 2 to 3 hours d. Provide the patient with current newspapers and magazines

a. Nitrazine strip test

A patient who is 35 weeks pregnant states she thinks her "water broke" but she isn't sure because it is a very little amount. What do you anticipate the MD will order first? a. Nitrazine strip test b. Ultrasound c. Nonstress test d. Order oxytocin IV

a. Denial

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? a. Denial b. Conversion c. Dissociation d. Displacement

d. Hyperreflexia of the deep tendons

A patient with a magnesium level of 3.6 would exhibit which of the signs and symptoms EXCEPT? a. Hypotension b. Profound Lethargy c. Respiratory failure d. Hyperreflexia of the deep tendons

d. Give slowly and watch for signs and symptoms of cerebral edema

A patient with a sodium level of 178 is ordered to be started on 0.45% Saline. What is the most IMPORTANT nursing intervention for this patient? a. Maintain patent IV b. Give rapidly to ensure fluids levels are shifted properly c. Clarify doctor's order because 0.45% saline is contraindicated in hypernatremia d. Give slowly and watch for signs and symptoms of cerebral edema

d. "Does the pain keep you from doing things you enjoy?" **goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions also are appropriate to ask, but information about patient function is more useful in evaluating effectiveness.

A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Can you describe the quality of your pain?" b. "Has there been a change in the pain location?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does the pain keep you from doing things you enjoy?"

a. Administering I.V. and oral fluids.

A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark's care. Which nursing intervention should be included in the care plan of Mark for his patient? a. Administering I.V. and oral fluids. b. Clustering necessary activities throughout the day. c. Assessing color, odor, and amount of sputum. d. Monitoring serum albumin and total protein levels.

b. Respirations of 10 breaths/minute d. Urine output of 20 mL in an hour **signs of toxicity: respiratory depression, loss of DTRs, sudden decline in FHR and maternal HR and BP, respiratory rate <12/min, urine output <25 mL/hr

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? (Select all that apply) a. Proteinuria of 3+ b. Respirations of 10 breaths/minute c. Presence of deep tendon reflexes d. Urine output of 20 mL in an hour e. Serum magnesium level of 4 mEq/L

c. Elevated hCG levels

A pregnant patient in her first trimester is complaining of nausea. The patient asks why she feels so sick. The nurse explains that anorexia and nausea are common in the first trimester of pregnancy because why? a. Low iron levels b. Nocturia c. Elevated hCG levels d. Heartburn and constipation

d. Turn the woman on her left side. **This woman is experiencing supine hypotension as a result of uterine compression of the vena cava and abdominal aorta. Turning her on her side will remove the compression and restore cardiac output and blood pressure

A pregnant woman at 32 weeks' gestation complains of feeling dizzy and lightheaded while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to: a. Assess the woman's blood pressure and pulse. b. Have the woman breathe into a paper bag. c. Raise the woman's legs. d. Turn the woman on her left side.

a. Minimize background noises and ensure that lighting is adequate to see the nurse's face

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do? a. Minimize background noises and ensure that lighting is adequate to see the nurse's face b. Use written communication whenever possible in order to minimize Mr. Fields' frustration c. Use vocabulary and concepts that are as simple and unambiguous as possible d. Repeat each direction or question in different terms in order to maximize understanding

c. "None of the kids at this school like me, and I don't like them either" **(risk for depression, eating disorders, self harm)

A school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address? a. "My parents treat me like a baby sometimes" b. "I haven't gotten my period yet, and all my friends have theirs" c. "None of the kids at this school like me, and I don't like them either" d. "There's a big pimple on my face, and I worry that everyone will notice it"

a. Lethargy b. Increased pulse rate d. Decreased urine output

A surgical client is admitted to the ICU following abdominal surgery. Which clinical manifestation would the nurse recognize as an indication of decreased cardiac​ output? (Select all that​ apply) a. Lethargy b. Increased pulse rate c. Capillary refill less than <3 seconds d. Decreased urine output e. Palpable pedal pulses

d. Gather more information about the wife's preferences and determine whether the husband is her power of attorney for health care.

A woman has severe life-threatening injuries, is unresponsive, and is hemorrhaging following a car accident. The health care provider ordered two units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? a. Obtain a court order to give the blood. b. Convince the husband to allow the nurse to give the blood. c. Call security and have the husband removed from the hospital. d. Gather more information about the wife's preferences and determine whether the husband is her power of attorney for health care.

b. Seizures do not occur

A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective? a. Scotomas are present b. Seizures do not occur c. Ankle clonus is noted d. The blood pressure decreases

d. arthroplasty **hip surgery

Acute delirium is mostly associated with which of the following disease processes? a. amputation b. fibromyalgia c. compartment syndrome d. arthroplasty

a. Cluster

Administration of 100% oxygen can be used as symptomatic therapy for which headache type? a. Cluster b. Migraine c. Tension-Type

c. the ability to achieve and maintain high standards of care. d. access to standard plans of care for many health problems. e. improved communication of the patient's health status to the health care team.

Advantages of using informatics in health care delivery are.... (Select all that apply) a. reduced need for nurses in acute care. b. increased patient anonymity and confidentiality. c. the ability to achieve and maintain high standards of care. d. access to standard plans of care for many health problems. e. improved communication of the patient's health status to the health care team.

c. "Would you like for me to sit down with you for a few minutes so you can talk about this?"

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. The nurse's first response is which of the following? a. "Don't be sad. People live with cancer every day." b. "Have you thought about how you are going to tell your family?" c. "Would you like for me to sit down with you for a few minutes so you can talk about this?" d. "I know another patient whose colon cancer was cured by surgery."

c. "I will try to lie down someplace dark and quiet when the headaches begin."

After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says... a. "I will take the (Topamax) as soon as any headaches start." b. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time." c. "I will try to lie down someplace dark and quiet when the headaches begin." d. "A glass of wine might help me relax and prevent headaches from developing."

a. Improve her quality of life d. Focus on reducing the severity of disease symptoms

An 80-yr-old female patient is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to do which of the following? (Select all that apply) a. Improve her quality of life b. Assess her coping ability with disease c. Have time to teach patient and family about disease d. Focus on reducing the severity of disease symptoms e. Provide care that the family is unwilling or unable to give

c. Stage 3

An 82year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

d. Asking the patient to describe previous stressful situations and how she managed to resolve them

An appropriate nursing intervention for a hospitalized patient who states she cannot cope with her illness is which of the following? a. Controlling the environment to prevent sensory overload and promote sleep b. Encouraging the patient's family to offer emotional support by frequent visiting c. Arranging for the patient to phone family and friends to maintain emotional bonds d. Asking the patient to describe previous stressful situations and how she managed to resolve them

c. believe what the patient says about the pain

An important nursing responsibility related to pain is to do which of the following? a. leave the patient alone to rest b. help the patient appear to not be in pain c. believe what the patient says about the pain d. assume responsibility for eliminating the patient's pain

c. 16 lbs **should double by 6 months

An infant weighed 8 pounds at birth. How many pounds should the infant weigh at 6 months? a. 24 lbs b. 10 lbs c. 16 lbs d. 32 lbs

d. Your provider needs to consult with you concerning your desires for DNR

An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a DNR case. Which of the following nurse responses is appropriate? a. This is a minor procedure, there will be no need to have a DNR b. You need to let your provider know your wishes after the procedure c. You need to discuss your wants with the hospital chaplain d. Your provider needs to consult with you concerning your desires for DNR

c. Face the patient when speaking; demonstrate ideas you wish to convey. e. Verify that the information that has been given has been clearly understood.

An older adult patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? (Select all that apply) a. Talk to the patient at a distance so he or she may read your lips. b. Keep your arms at your side; speak directly into the patient's left ear. c. Face the patient when speaking; demonstrate ideas you wish to convey. d. Position the patient so that the light is on his or her face when speaking. e. Verify that the information that has been given has been clearly understood.

a. weight loss. b. dry oral mucosa.

An older woman is admitted to the medical unit with GI bleeding. Assessment findings that indicate fluid volume deficit include (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins.

b. ibuprofen (Advil) d. acetaminophen (Tylenol)

Appropriate nonopioid analgesics for mild pain include which of the following? (select all that apply) a. oxycodone b. ibuprofen (Advil) c. lorazepam (Ativan) d. acetaminophen (Tylenol) e. codeine with acetaminophen

c. encourage fluids to decrease the urine concentration so it is less irritating

Appropriate nursing care for a patient with urinary incontinence is to do which of the following? a. insert an indwelling Foley catheter b. restrict their fluids c. encourage fluids to decrease the urine concentration so it is less irritating d. recommend herbal approaches to reduce incontinence.

b. "Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer."

As part of a faith community nursing program in her church, a nurse is developing a health promotion program on breast self-examination for the women's group. Which statement made by one of the participants is related to the individual's accurate perception of susceptibility to an illness? a. "I have a door hanging tag in my bathroom to remind me to do my breast self-examination monthly." b. "Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer." c. "Since I am only 25 years of age, the risk of breast cancer for me is very low." d. "I participate every year in our local walk/run to raise money for breast cancer research."

c. Sit without support

At 8-9 months of age, what milestone should an infant be able to successfully perform? a. Begin walking b. Say several words like "mama" or "dada" c. Sit without support d. Follow basic commands

d. Care-related

At the end of the 12 hour shift the nurse is evaluating with the patient the following goal that was set: "Mr. Jones will ambulate 100 feet in the hall 3 times during the shift." The goal was not met, as Mr. Jones only ambulated in the morning after breakfast as the CNA went home sick before lunch, leaving the nurses with extra duties. This would be what type of variance? a. Client-related b. Clinical outcome c. Quality-related outcome d. Care-related

b. 4 months

At what age would you educate the parents of an infant to stop swaddling the infant because the infant will be able to roll over onto its tummy? a. 2 months b. 4 months c. 6 months d. 10 months

c. Stress

A​ 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor would the nurse​ assess? a. Family History b. Age c. Stress d. Sex

c. "What do you think is the greatest reason why stopping smoking would be challenging for you?"

Based on the Transtheoretical Model of Change, what is the most appropriate response to a patient who states: "Me, stop smoking? I've been smoking since I was 16!" a. "That's fine. Some people who smoke live a long life." b. "OK. I want you to decrease the number of cigarettes you smoke by one each day, and I'll see you in 1 month." c. "What do you think is the greatest reason why stopping smoking would be challenging for you?" d. "I'd like you to attend a smoking-cessation class this week and use nicotine replacement patches as directed."

a. Reassess the client to determine the reasons for inadequate pain relief

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take? a. Reassess the client to determine the reasons for inadequate pain relief b. Wait to see whether the pain lessens during the next 24 hours c. Change the plan of care to provide different pain relief interventions d. Teach the client about the plan of care for managing the pain

d. Syndrome characterized by cognitive dysfunction and loss of memory

Dementia is defined as which of the following? a. Syndrome that results only in memory loss b. Disease associated with abrupt changes in behavior c. Disease that is always due to reduced blood flow to the brain d. Syndrome characterized by cognitive dysfunction and loss of memory

b. perception

Determination of whether an event is a stressor is based on a person's... a. tolerance b. perception c. adaptation d. stubbornness

b. Increased sodium intake **Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration. Increased sodium intake is part of the management of this condition

Dietary recommendations for a patient with a hypotonic fluid excess should include: a. Decreased sodium intake b. Increased sodium intake c. Increased fluid intake d. Intake of potassium-rich foods

d. overflow

Double voiding is a care management strategy that is most effectively used for which type of incontinence? a. reflex b. urge c. stress d. overflow

a. Sardines d. Craft beer **these are high in purines

During a home health visit you are helping a patient with gout identify foods in their pantry they should avoid eating. Select all the foods below the patient should avoid. a. Sardines b. Whole wheat bread c. Crackers d. Craft beer

b. Gravida 6, para 2

During a medical history collection the patient states she has been pregnant six times and has delivered 2 babies at 38 and 39 weeks. She reports losing 4 pregnancies at 5, 7, 8, and 10 weeks gestation. Which option below best describes the patient's gravidity and parity? a. Gravida 6, para 6 b. Gravida 6, para 2 c. Gravida 8, para 2 d. Gravida, 2, para 6

c. June 4, 2017

During a prenatal visit a patient tells you her last menstrual period was August 28, 2016. Based on the Naegele's Rule, when is the estimated due date of her baby? a. July 4, 2017 b. June 3, 2017 c. June 4, 2017 d. July 1, 2016

c. February 28, 2017

During a prenatal visit a patient tells you her last menstrual period was May 21, 2016. Based on the Naegele's Rule, when is the estimated due date of her baby? a. February 27, 2016 b. March 19. 2017 c. February 28, 2017 d. April 16, 2016

c. Provide the toddler with a favorite stuffed animal at bedtime

During a well-child visit, the guardian of a toddler reports that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make? a. Vary the time the toddler goes to bed each night b. Allow the toddler to watch television before bedtime c. Provide the toddler with a favorite stuffed animal at bedtime d. Increase the toddler's activity prior to bedtime

a. G: 5, T: 3, P: 0, A: 1, L: 3

During an assessment of a pregnant patient (who is 20 weeks pregnant) she tells you the following information regarding her pregnancy outcomes: She currently has 3 children (ages: 3, 8, 19), all of them were born at 39 and 40 weeks gestation, she has been pregnant 5 times (including this pregnancy). How would you document her GTPAL? a. G: 5, T: 3, P: 0, A: 1, L: 3 b. G: 4, T: 3, P: 0, A: 0, L: 4 c. G: 4, T: 4, P: 0, A: 0, L: 3 d. G: 5, T: 3, P: 0, A: 1, L: 4

c. Signs of placental separation **Signs that the placenta is about to be delivered include umbilical cord starts to lengthen, rrickling/gush of blood, and uterus changes from an oval shape to globular

During stage 3 of labor, you note a gush of blood and that the uterus changes shape from an oval shape to globular shape. This indicates? a. Postpartum hemorrhage b. Imminent delivery of the baby c. Signs of placental separation d. Answers B and C

c. Keep blinds open during the daytime hours

During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Provide hourly orientation to time of day b. Move the patient to a quieter room at night c. Keep blinds open during the daytime hours d. Have the patient take a brief mid-morning nap

d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.

During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. water accounts for a greater percentage of body weight in the older adult than in younger adults. c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.

a. Positive maternal-infant relationship

During the visit to the pediatric office, a nurse observes the mother frequently looking at the infant and massaging the infant. From these observations, the nurse's conclusion should be: a. Positive maternal-infant relationship b. Inadequate; more data are needed to assess the mother-infant relationship c. That the mother might be overwhelmed by the demands of infant care d. That the mother is trying to show the nurse that she can be affectionate to the infant

b. hip flexion contracture

Elevation after amputation of a lower limb can lead to what? a. ischemia b. hip flexion contracture c. acute delirium d. edema

d. constipation

Even though most side effects will decrease over time with opioids specifically, which side effect does NOT? a. reduced respirations b. sedation c. nausea d. constipation

a. developmental status b. timing c. support system

Factors that can positively impact learning include which of the following? (Select all that apply) a. developmental status b. timing c. support system d. lengthy lecture presentations

a. deoxygenated blood, oxygenated blood.

Fill in the blank: In fetal circulation the umbilical artery carries _____________, while the umbilical vein carries ________________. a. deoxygenated blood, oxygenated blood. b. deoxygenated, oxygenated blood c. oxygenated blood, oxygenated blood. d. deoxygenated blood, deoxygenated blood

c. Reposition the client every 2 hr.

For someone who is confined to bed, which is an action to be included in the plan? a. Massage the client's red bony prominences. b. Assess the client's skin for increased coolness. c. Reposition the client every 2 hr. d. Keep the client's skin moist.

b. triptans

For symptomatic drug therapy for a moderate to severe migraine, what drug therapies can be utilized? a. opioids b. triptans c. NSAIDs d. Tylenol

d. Prolonged grief

For the past 5 years, Tom as repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is she experiencing? a. Adaptive grief b. Disruptive grief c. Anticipatory grief d. Prolonged grief

c. is an appropriate nursing action

Giving opioids to an actively dying patient who has moderate to severe pain... a. may cause addiction b. will likely be ineffective c. is an appropriate nursing action d. will likely hasten the person's death

c. the number of times a woman has been pregnant regardless of the outcome.

Gravidity is defined as which of the following? a. the number of completed pregnancies at 20 weeks or greater. b. the number of pregnancies greater than 20 weeks. c. the number of times a woman has been pregnant regardless of the outcome. d. the number of births regardless of the outcome.

b. Hypotonic **hypotonic solutions move fluid into veins, which can lead to rupture/hemolysis of cells

Hemolysis can occur with the administration of which of the following types of solution? a. Isotonic b. Hypotonic c. Hypertonic

d. Remove gloves b. Remove protective eyewear e. Remove gown a. Remove mask c. Perform hand hygiene

How should a nurse remove PPE when leaving the client's room? Place in correct order. a. Remove mask b. Remove protective eyewear c. Perform hand hygiene d. Remove gloves e. Remove gown

c. Assess for beating of the foot when the foot is quickly dorsiflexed.

How would the nurse check for clonus in a patient with preeclampsia? a. Assess the patellar and bicep tendon with a reflex hammer and grade the reaction. b. Assess for muscular rigidity by having the patient extend the arms and place resistance against the arms. c. Assess for beating of the foot when the foot is quickly dorsiflexed. d. Assess for dorsiflexion of the foot by quickly plantar flexing the foot.

a. hyperparathyroidism c. malignancy

Hypercalcemia can be caused by what? (Select all that apply) a. hyperparathyroidism b. excessive intake of dairy c. malignancy d. excessive vomiting/diarrhea

c. The patient will perform self breast exams correctly on herself by the end of the teaching session.

Identify the best learning outcome for a nurse teaching self breast exams. a. The nurse will explain the importance of performing monthly self breast exams. b. The patient will verbalize the steps involved in breast self-examination within a week. c. The patient will perform self breast exams correctly on herself by the end of the teaching session. d. The nurse will demonstrate a self breast exam on a breast model provided by the American Cancer society.

b. 0.25

If Phenergan is available in 100 mg/2 mL ampules, which of the following represents the amount is needed in mL to give a dose of 12.5 mg IM? a. 0.20 b. 0.25 c. 0.50 d. 0.75

c. Erythema, swelling

If an IV has become infiltrated, the nurse will observe which of the following assessment findings? a. Pallor, pain b. Erythema, warmth c. Erythema, swelling d. Warmth, swelling

c. Awareness of a full stomach **somatic complaint = highly aware of discomforts

In responding to a somatic complaint, the nurse would expect which of the following? a. Being aware train is coming because of hearing whistle b. Being aware of which foot is forward when walking c. Awareness of a full stomach d. Being aware of an unpleasant smell

c. 4-7 cm

In stage 1 of labor, during the active phase, the cervix dilates? a. 1-3 cm b. 7-10 cm c. 4-7 cm d. 8-10 cm

d. lifestyle modifications are indicated for all persons with elevated BP

In teaching a patient with hypertension about controlling the illness, the nurse recognizes that which of the following is true? a. all patients with elevated BP require medication b. obese persons must achieve a normal weight to lower BP c. it is not necessary to limit salt in the diet if taking a diuretic d. lifestyle modifications are indicated for all persons with elevated BP

a. primary

In this level of prevention, you as the nurse must help with wellness education and encourage behavioral actions such as wearing a bike helmet or receiving immunizations. Which level of prevention is this? a. primary b. secondary c. tertiary d. transtheoretical

b. Mood swings most likely are the result of worries about finances and a changed lifestyle, as well as profound hormonal changes

In understanding and guiding a woman through her acceptance of pregnancy, a maternity nurse should be aware of which of the following? a. Nonacceptance of the pregnancy very often equates to rejection of the child b. Mood swings most likely are the result of worries about finances and a changed lifestyle, as well as profound hormonal changes c. Ambivalent feelings during pregnancy usually are seen only in emotionally immature or very young mothers d. Conflicts such as not wanting to be pregnant or childrearing and career-related decisions need not be addressed during pregnancy because they will resolve themselves naturally after birth

c. immediately discard the needle and syringe in a puncture-proof container

In which of the following ways can a nurse prevent injury from a needlestick? a. recap the needle before disposal b. remove the needle from the syringe c. immediately discard the needle and syringe in a puncture-proof container d. stick it into the patient's mattress until it can be disposed of.

d. Perspiration

Insensible fluid losses include which of the following? a. Urine b. Gastric drainage c. Bleeding d. Perspiration

b. Fibromyalgia

Irritable bowel syndrome is a potential sign and symptom of which disease process? a. Osteoarthritis b. Fibromyalgia c. Pyelonephritis d. Pressure injuries

b. contemplation

Jack is a 70 year old retired male who lives with his wife in small town in Bellevue Nebraska. He has peripheral arterial disease, arterial hypertension and has smoked one pack of cigarettes a day for 50 years. Jack was admitted to the hospital and underwent a successful femoral popliteal bypass to reverse the effects of critical limb ischemia. Jack expressed a wish to give up smoking four days after surgery, and asked nursing staff for advice and information on available support. What stage of change is Jack at using the transtheoretical model of change? a. not ready b. contemplation c. prepared d. terminating change

d. Attempting to rule out complications before administering pain medication.

Jack was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse do? a. Administering the client's ordered pain medication immediately. b. Using guided imagery instead of administering pain medication. c. Using therapeutic conversation to try to discourage pain medication. d. Attempting to rule out complications before administering pain medication.

a. Tented skin turgor and thirst

Lab tests revealed that patient Z's [Na+] is 170 mEq/L. Which clinical manifestation would the nurse expect to assess? a. Tented skin turgor and thirst b. Muscle twitching and tetany c. Fruity breath and Kussmaul's respirations d. Muscle weakness and paresthesia

a. GI

Magnesium is absorbed by what system of the body? a. GI b. Hepatic c. Renal d. Lymphatic

a. Positive Trousseau's sign

Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? a. Positive Trousseau's sign b. Positive Chvostek's sign c. Tetany d. Paresthesia

d. Turn the client to the right side for 2 hours.

Maya, who is admitted to a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first? a. Massage the reddened area for a few minutes. b. Notify the physician immediately. c. Arrange for a pressure-relieving device. d. Turn the client to the right side for 2 hours.

b. Blood pressure

Methergine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? a. Uterine tone b. Blood pressure c. Amount of lochia d. Deep tendon reflexes

c. stress and urge

Mixed incontinence is usually a combination of which two types of incontinence? a. overflow and reflex b. urge and transient c. stress and urge d. functional and reflex

a. Gaining an understanding of the patient's motivations c. Recognizing the patient's strengths and supporting his or her efforts e. Identifying differences in patient's health goals and current behaviors

Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavioral changes. When using motivational interviewing, what outcomes does the nurse expect? (Select all that apply) a. Gaining an understanding of the patient's motivations b. Directing the patient to avoid poor health choices c. Recognizing the patient's strengths and supporting his or her efforts d. Providing assessment data that can be shared with families to promote change e. Identifying differences in patient's health goals and current behaviors

d. maintenance

Mr. Jones was just discharged from the hospital after an acute exacerbation of his congested heart failure. His optimal level of health was restored in the hospital by increased his dose of Lasix, a diuretic medication. What state of health is Mr. Jones at? a. promotion b. restoration c. preventative d. maintenance

c. Caregivers rarely take care of themselves and are at risk for poor health

Mr. P has been caring for his wife with end-stage Alzheimer's disease for the past three years. Mrs. P is admitted to your unit for pneumonia. Mr. P rarely takes a break to eat and sleeps in the hospital every night. You are concerned about his hospital routine why? a. It is not healthy for him to sleep in the hospital since he could get sick himself b. Mrs. P doesn't even recognize him anymore and doesn't need him to be there c. Caregivers rarely take care of themselves and are at risk for poor health d. It is disruptive to the unit to have Mr. P staying with his wife all the time

a. Normal grief

Mrs. Jones is experiencing difficulty sleeping and eating. It has been a month since her husband died, and she has come to the unit to thank the nurses for their excellent care. As the nurse that cared for Mr. Jones, you recognize that his wife is experiencing which of the following? a. Normal grief b. Complicated grief c. Disenfranchised grief d. Anticipatory grief

c. Keeping the linens dry and wrinkle-free.

Mrs. Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client's need to maintain skin integrity? a. Monitoring intake and output accurately. b. Instructing the client to cough and deep breathe every 2 hours. c. Keeping the linens dry and wrinkle-free. d. Using a footboard to maintain correct anatomic position.

b. Maintaining correct body alignment at all times. d. Performing active and passive range-of-motion exercises.

Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? (Select all that apply) a. Clustering activities to allow uninterrupted periods of rest. b. Maintaining correct body alignment at all times. c. Monitoring intake and output, using a urometer if necessary. d. Performing active and passive range-of-motion exercises.

b. nifedipine

Nurse is caring for a pt who is at 28 weeks gestation and experiencing preterm labor. Which of the following medications should the nurse plan to administer? a. oxytocin b. nifedipine c. dinoprostone d. misoprostol

b. To reduce the risk of errors to the patient c. To provide an optimum level of patient care d. To improve patient outcomes

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply) a. To improve the nurse's status with the health team members b. To reduce the risk of errors to the patient c. To provide an optimum level of patient care d. To improve patient outcomes e. To prevent issues that need to be reported to outside agencies

b. cluster headaches **3x more likely in men then women

Of the following disease processes, which is more common in men than in women? a. urinary tract infections b. cluster headaches c. fibromyalgia d. osteoarthritis

b. Taking Hold Phase

On the end of the first postpartum day, the nurse is discussing routine infant care with Laura and her husband, Tom. The nurse notes that Laura asks few questions and prefers to focus on her perineal pain and complaints of hunger. Laura asks Tom to hold the baby, as she is "just too tired". Which phase is Laura in at this time? a. Letting Go Phase b. Taking Hold Phase c. Taking In Phase

a. The baby's head is pressing against the pelvis or soft tissue

On the fetal heart monitor you see early decelerations. What is the cause of this finding? a. The baby's head is pressing against the pelvis or soft tissue b. It is due to uteroplacental insufficiency. c. It is caused by cord compression. d. It is caused by a prolapsed uterus.

d. Taking-in phase **taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives

On the first postpartum (PP) night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases? a. Depression phase b. Letting-go phase c. Taking-hold phase d. Taking-in phase

c. men with an enlarged prostate

Overflow incontinence is seen most often in which patient population? a. sexually active young females b. pregnant women c. men with an enlarged prostate d. men who had surgical removal of the prostate

d. the number of completed pregnancies at 20 weeks or greater.

Parity is defined as which of the following? a. the number of babies born at 20 weeks or greater. b. the number of pregnancies greater than 36 weeks. c. the number of births at 20 weeks or less. d. the number of completed pregnancies at 20 weeks or greater.

a. Assessing dietary intake **Assessing dietary intake provides a foundation for the client's usual practices and may help determine if the client is prone to constipation or diarrhea. Check out usual dietary habits, eating habits, eating schedule, and liquid intake

Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function? a. Assessing dietary intake b. Decreasing fluid intake c. Providing limited physical activity d. Turning, coughing, and deep breathing

b. Primigravida c. BMI 34 d. Pregnant with twins e. Maternal history of preeclampsia

Select all the risk factors below that increases a woman's risk for developing preeclampsia: a. Nulligravida b. Primigravida c. BMI 34 d. Pregnant with twins e. Maternal history of preeclampsia

d. Latent, Active, Transition

Stage 1 of labor includes which phases in the correct order? a. Transition, Latent, Active b. Active, Latent, Transition c. Active, Transition, Latent d. Latent, Active, Transition

b. Chvostek's Sign

Stimulation of the facial nerve via the masseter muscle causes twitching of the nose/lips in hypocalcemia is known as?* a. Trousseau's Sign b. Chvostek's Sign c. Homan's Sign d. Goodell's Sign

a. Log off the computer, so the AP can use the computer.

Tami has logged into the computer and is familiarizing herself with the hospital data system. An assistive personnel (AP) needs to use the computer. Which of the following actions should she take? a. Log off the computer, so the AP can use the computer. b. Allow the AP to use the computer while she is still logged in. c. Suggest the AP write the data down and place it in the computer herself.

a. Sugar b. Alcohol c. Caffeine

Teach the patient with fibromyalgia the importance of limiting intake of which foods? (Select all that apply) a. Sugar b. Alcohol c. Caffeine d. Red meat e. Root vegetables

b. "I am making sure your baby brother is doing okay. Would you like to help me look him over"?

The 4-year-old sibling of a new baby comes in with the parents for the newborn's first health supervision visit and asks multiple questions about the baby and what the nurse is doing. Which statement is most indicative of therapeutic communication with this child? a. "I know you must have lots of questions. Your parents will be able to talk to you about all of it later" b. "I am making sure your baby brother is doing okay. Would you like to help me look him over"? c. "Your parents brought your brother in to us make sure he is doing okay, so can you ask your questions later"? d. "I think your questions are distracting me, can you read this book for me while I finish this exam"?

d. Cataracts **cataracts lead to vision being cloudy and blurred, which is how glasses might appear when they are dirty

The 65 yr old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? a. Macular degeneration b. Conjunctivitis c. Diabetic retinopathy d. Cataracts

c. Atherosclerosis **Atherosclerosis is the most common cause of PAD bc it blocks blood flow due to the collection of fatty plaques on the artery wall

The MOST common cause of peripheral arterial disease is which of the following? a. Diabetes b. Deep vein thrombosis c. Atherosclerosis d. Pregnancy

b. A more bounding pulse **During this shock phase, the sympathetic nervous system is stimulated, resulting in increased myocardial contractility, which would be reflected in the client as a bounding pulse

The client has just received news of the death of a relative. Over the next few hours, what physiologic response should the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event? a. Drop in blood pressure from 130/80 to 120/75 b. A more bounding pulse c. Slight increase in urine output d. Some decrease in oxygen saturation

d. patient history and cognitive assessment

The clinical diagnosis of dementia is based on which of the following? a. CT or MRS b. brain biopsy c. electroencephalogram d. patient history and cognitive assessment

b. Memory problems and mild confusion

The early stage of Alzheimer's disease is characterized by which of the following behaviors? a. No noticeable change in behavior b. Memory problems and mild confusion c. Increased time spent sleeping or in bed d. Incontinence, agitation, and wandering behavior

b. Development of beta-amyloid plaques in between neurons d. Creation of neurofibrillary tangles within the neuron

The exact cause of Alzheimer's disease is not fully understood. However, what two changes in the brain are found in a patient with this disease? (Select all that apply) a. Destruction of the myelin sheath on the neuron b. Development of beta-amyloid plaques in between neurons c. Destruction of dopaminergic neurons d. Creation of neurofibrillary tangles within the neuron

b. Use of warm incandescent lighting c. Use of yellow or amber lenses to decrease glare d. Use of adjustable blinds, sheer curtains, or draperies

The home care nurse is instructing an assistive personnel about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply) a. Use of fluorescent lighting b. Use of warm incandescent lighting c. Use of yellow or amber lenses to decrease glare d. Use of adjustable blinds, sheer curtains, or draperies e. Indirect lighting to reduce glare

d. A 72-year-old female is unable to locate the address where she has lived for 10 years **An early warning sign of Alzheimer's disease is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a clinical manifestation of middle or moderate dementia (or Alzheimer's disease). Incontinence and inability to perform self-care activities are clinical manifestations of severe or late dementia (or Alzheimer's disease)

The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease? a. A 65-year-old male does not recognize his family members and close friends b. A 59-year-old female misplaces her purse and jokes about having memory loss c. A 79-year-old male is incontinent and not able to perform hygiene independently d. A 72-year-old female is unable to locate the address where she has lived for 10 years

c. the child eats raw carrots for lunch 3-4 days a week **choking hazards

The home health nurse evaluates the home environment of a 2-year-old toddler. Which of the following findings cause the nurse to intervene? a. there are several live green plants hanging from the hooks in the bathroom b. the child is transported in the back seat of a car using a front facing car seat c. the child eats raw carrots for lunch 3-4 days a week d. household cleaners are kept on the top shelf of a locked cabinet in the kitchen

c. communication

The most frequently cited factor involved in a sentinel event is related to which of the following? a. incompetence b. malpractice c. communication d. confusion

b. Distract the child d. Prepare the child for a change in activity or an event a few minutes before it occurs e. Avoid new activities when the child is hungry or tired

The mother of a 2-year-old verbalizes concern about how her child has suddenly developed temper tantrums. She asks about preventive measures. What are some preventive measures you can educate the mother about? (Select all that apply) a. Avoid giving the child choices b. Distract the child c. Give in to the child's request d. Prepare the child for a change in activity or an event a few minutes before it occurs e. Avoid new activities when the child is hungry or tired

a. "Children this age enjoy being with each other during play time, even though they may not communicate with each other"

The mother of a 3-year-old child and the nurse observe the child playing with a set of building blocks beside another child playing with blocks. The mother says, "I worry that my child is not interacting with other children". Which response by the nurse is the MOST appropriate? a. "Children this age enjoy being with each other during play time, even though they may not communicate with each other" b. "If we give the children a puzzle, they will talk as they work on the puzzle together" c. "The attention span of children this age is short. We need to give them different toys frequently" d. "If you start talking with the other child, your child will imitate you and join the conversation"

a. Excess fluid volume related to the kidney's inability to maintain fluid balance.

The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Based on these data, which of the following nursing diagnoses is appropriate? a. Excess fluid volume related to the kidney's inability to maintain fluid balance. b. Increased cardiac output related to fluid overload. c. Ineffective tissue perfusion related to interrupted arterial blood flow. d. Ineffective Therapeutic Regimen Management related to lack of knowledge about therapy.

a. In a side-lying position

The nurse caring for a pregnant woman knows that her health teaching regarding fetal circulation has been effective when the woman reports that she has been sleeping in which way? a. In a side-lying position b. On her back with a pillow under her knees c. With the head of the bed elevated d. On her abdomen

c. Ensure no visitors or staff enter the room for a short period of time

The nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? a. Contact the hospital's spiritual services b. Ask what is making the client cry c. Ensure no visitors or staff enter the room for a short period of time d. Turn on the television for a distraction

a. Sensorineural hearing loss that occurs with aging

The nurse has notes that the physician has a diagnosis of Presbycusis on the client's chart. The nurse plans care knowing the condition is which of the following? a. Sensorineural hearing loss that occurs with aging b. Conductive hearing loss that occurs with aging c. Tinnitus that occurs with aging d. Nystagmus that occurs with aging

c. holistic health model

The nurse implements meditation and music therapy into her patient's plan of care since it helps the patient's anxiety levels diminish. What model of health is this representative of? a. health beliefs model b. health promotion model c. holistic health model d. basic human needs model

b. 43-year-old with a BP of 190/102 who is complaining of chest pain **The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes

The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 52-year-old with a BP of 212/90 who has intermittent claudication b. 43-year-old with a BP of 190/102 who is complaining of chest pain c. 50-year-old with a BP of 210/110 who has a creatinine of 1.5 mg/dL d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria

b. Provide thickened fluids and moist foods in bite-size pieces

The nurse in the long-term care facility cares for a 70-year-old man with severe (late-stage) dementia who is undernourished and has problems chewing and swallowing. What should the nurse include in the plan of care for this patient? a. Turn on the television to provide a distraction during meals b. Provide thickened fluids and moist foods in bite-size pieces c. Limit fluid intake during scheduled meals to prevent aspiration d. Allow the patient to select favorite foods from the menu choices.

c. Decreased uterine bleeding **used to prevent or control postpartum hemorrhage by contracting the uterus

The nurse in the postpartum unit notes that a new mother was given Methergine intramuscularly following delivery. What assessment finding indicates that the medication was effective? a. Lochia that is serous b. Normal blood pressure c. Decreased uterine bleeding d. Decreased uterine contractions

b. understanding the reason for the specimen

The nurse instructs the patient about providing a urine specimen. Which of the following indicates the cognitive domain of learning? a. physically obtaining the specimen b. understanding the reason for the specimen c. willingly obtaining the specimen

a. Assess for signs and symptoms of labor.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client? a. Assess for signs and symptoms of labor. b. Assess the client's temperature every 2 hours. c. Schedule a daily ultrasound to assess fetal movement. d. Schedule a non-stress test every 4 hours to assess fetal well-being.

a. Lower extremity edema b. Cyanosis of lower legs **Manifestations of CVI include lower extremity edema that worsens with​ standing; itching, dull leg discomfort or pain that increases with​ standing; thin,​ shiny, atrophic​ skin; cyanosis and brown skin pigmentation of lower leg and​ foot; possible weeping​ dermatitis; thick, fibrous​ (hard) subcutaneous​ tissue; and recurrent ulcerations of medial or anterior ankles.

The nurse is assessing a client diagnosed with chronic vascular insufficiency​ (CVI). Which assessment finding should the nurse​ expect? (Select all that​ apply) a. Lower extremity edema b. Cyanosis of lower legs c. Soft subcutaneous tissue on affected areas on leg d. Excessive hair growth on the legs d. Pale skin on lower legs

b. Hypertension and diabetes mellitus **risk for increased IOP and diabetic retinopathy

The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? a. Hypothyroidism and polycythemia b. Hypertension and diabetes mellitus c. Atrial fibrillation and atherosclerosis d. Vascular dementia and chronic fatigue

b. A fetal heart rate of 90 beats/min

The nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? a. Increased urinary output b. A fetal heart rate of 90 beats/min c. Three contractions occurring within a 10-minute period d. Adequate resting tone of the uterus palpated between contractions

d. A widespread pain index **pain is widespread throughout the body in someone with fibromyalgia

The nurse is caring for a client with suspected fibromyalgia. Which diagnostic tool does the nurse anticipate will be used to properly diagnose this​ client? a. Blood tests for neurotransmitter levels b. Abnormalities on a thyroid panel c. Failure of a cardiac stress test d. A widespread pain index

a. Healthy eating b. Teaching about body changes c. Establishment of baseline data e. Taking prenatal vitamins

The nurse is caring for a patient who presents to the clinic for her first prenatal visit. What should the nurse focus on teaching? a. Healthy eating b. Teaching about body changes c. Establishment of baseline data d. Parenting skills e. Taking prenatal vitamins f. Breastfeeding benefits

a. Eleven **must have 11/18

The nurse is completing a physical assessment on a client with possible fibromyalgia. To support the diagnosis of​ fibromyalgia, the nurse must assess and document pain upon palpation on how many standard tender​ points? a. Eleven b. Nine c. Five d. Eighteen

b. I may be able to dress more easily with zippers or pullover sweaters."

The nurse is conducting discharge teaching for a client with diminished tactile sensation. Which of the following statements by the client would indicate that teaching was ineffective? a. "I am at risk for injury from temperature extremes." b. I may be able to dress more easily with zippers or pullover sweaters." c. "A home care referral may help me achieve a maximum degree of independence." d. "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first."

c. "Your pain from the OA may increase due to the weight gain of​ pregnancy."

The nurse is counseling a newly pregnant client with osteoarthritis​ (OA). Which information should the nurse​ include? a. "Pregnancy has no impact on OA if you keep your weight gain within the recommended​ limits." b. ​"You need to restrict your participation in​ low-impact aerobic​ exercises." c. "Your pain from the OA may increase due to the weight gain of​ pregnancy." d. "You may continue to take your prescription nonsteroidal​ anti-inflammatory drug without any risk of harm to the​ fetus."

b. Use a reward system that includes food rewards

The nurse is developing a plan of care to help the school-age child and their caregiver implement diet changes to help decrease the child's obesity risk. Which intervention below should be avoided? a. Include the family members with setting weight and food goals b. Use a reward system that includes food rewards c. Substitute the child's favorite food with healthier options d. Consider team sports for the child

b. Avoid caffeine and alcohol. d. Limit physical exertion. **avoid substances such as caffeine and alcohol which are bladder irritants

The nurse is developing a teaching plan for a client with stress incontinence. Which of the following instructions should be included? (Select all that apply) a. Avoid activities that are stressful and upsetting. b. Avoid caffeine and alcohol. c. Do not drink more than 4 glasses of water a day. d. Limit physical exertion.

d. Assess the posterior tibial and pedal pulses **This client is describing symptoms of intermittent claudication. The nurse should assess the strength and equality of peripheral pulses to determine perfusion. Changes in skin color are important but not the priority

The nurse is evaluating a client who​ states, "I usually walk 30 minutes every​ morning, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop​ walking, though." Which action should the nurse do first​? a. Notify the healthcare provider b. Discuss benefits of daily exercise c. Ask the client about skin color changes d. Assess the posterior tibial and pedal pulses

c. "I'm going to let the occupational therapist assess my home to improve efficiency." e. "I'm going to attend a support group to learn more about multiple sclerosis."

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply) a. "I'm going to learn to drive a car, so I can be more independent." b. "My sister says she feels better when she goes shopping, so I'll go shopping." c. "I'm going to let the occupational therapist assess my home to improve efficiency." d. "I've always felt better when I go for a long walk. I'll do that when I get home." e. "I'm going to attend a support group to learn more about multiple sclerosis."

b. Clear simple directions

The nurse is helping a patient with Moderate Alzheimer's disease (Middle Stage) participate in a task. When selecting a task for the patient, the nurse would want to make sure the task has? a. Multiple steps b. Clear simple directions c. Critical thinking d. Usage of multiple tools

d. Delayed capillary refill in the lower extremities

The nurse is performing an assessment on a client with peripheral vascular disease​ (PVD). Which finding should the nurse​ expect? a. Wheezing upon auscultation of the lungs b. Decreased sensation of the upper extremities c. Dilated blood vessels in the eye d. Delayed capillary refill in the lower extremities

c. the residents will engage in the facility exercise program three times a week

The nurse is planning a program for older adults who have become very sedentary. the goal should restated as: a. the residents will demonstrate Tai Chi b. the residents will explain the importance of exercise c. the residents will engage in the facility exercise program three times a week d. the residents will feel better

c. bring in samples of foods to have them prepare and taste

The nurse is planning a teaching project for kindergarten children regarding nutrition. The best strategy would be to do which of the following? a. take them on a field trip to the grocery store b. have them cut out pictures of food groups c. bring in samples of foods to have them prepare and taste d. watch a video describing why they need to eat certain food groups

c. Continuous electronic fetal monitoring

The nurse is preparing to care for a client in labor. The health care provider has prescribed an IV infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? a. An IV infusion of antibiotics b. Placing the client on complete bed rest c. Continuous electronic fetal monitoring d. Placing a code cart at the client's bedside

d. Rephrase the direction in different terms **Rephrasing an instruction in simple terms may enhance a confused client's understand. This is preferable to proceeding in spite of the client

The nurse is preparing to reposition a confused client from a supine position to a side-lying position. The nurse has asked the client to shift her weight accordingly, but the client has not responded to the nurse's request. How should the nurse respond first? a. Reposition the client without the client's assistance b. Enlist the assistance of a colleague c. Ask the client if she is feeling confused d. Rephrase the direction in different terms

b. Use touch when appropriate c. Incorporate nonverbal communication d. Have music and imagery available during the day

The nurse is providing routine care for a patient with Severe Alzheimer's disease (late stage). The patient has no motor activities or language communication abilities. What are some nursing interventions the nurse can implement to promote patient interaction and communication? (Select all that apply) a. Limit interaction to verbal communication b. Use touch when appropriate c. Incorporate nonverbal communication d. Have music and imagery available during the day e. Identify yourself to the side of the patient rather than directly in front

b. Decreased sense of taste c. Decreased sense of hearing d. Impaired sense of smell

The nurse is reviewing the chart of an older adult client. Which sensory changes does the nurse anticipate have​ occurred? (Select all that​ apply) a. Increased tactile sensation b. Decreased sense of taste c. Decreased sense of hearing d. Impaired sense of smell e. Increased sense of taste

c. Stop smoking

The nurse is teaching a client about lifestyle modifications to promote vasodilation in a client with peripheral vascular disease​ (PVD). Which intervention should the nurse​ suggest? a. Wash extremities in cool water b. Walk daily c. Stop smoking d. Take an aspirin daily

d. ​"These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from​ forming."

The nurse is teaching a client with poor peripheral perfusion about the purpose of compression stockings. Which response by the nurse would be​ accurate? a. ​"You will notice that your skin will improve with the use of these stockings as they help protect your skin from​ injury." b. ​"These stockings will help to keep your blood pressure​ elevated, especially when you stand too​ quickly." c. ​"You will find that these stockings will help the heart pump more efficiently and increase the circulation to your lower​ extremities." d. ​"These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from​ forming."

a. demonstration of proper hand washing

The nurse is teaching a group of preschool children about preventing infections. On what should the nurse focus primarily? a. demonstration of proper hand washing b. exercise habits c. a film on how germs travel d. proper dietary intake

c. after 20 weeks

The nurse knows that preeclampsia tends to occur during what time in a pregnancy? a. before 20 weeks b. in the third trimester and postpartum c. after 20 weeks d. in the first and second trimester

a. "Tell me more about how you are feeling."

The nurse plans to return to initiate rapport and build trust with her client. Which of the following statements by the nurse displays an appropriate communication technique? a. "Tell me more about how you are feeling." b. "You really should be happy to have such a caring family." c. "I know you will do just fine. Just wait and see." d. "I have a lot of patients to get to, but I will try to explain your procedure to you."

a. when the pain medication is working **Choice D is wrong because the patient is likely hungry, and may be thinking about lunch instead

The nurse plans to teach a patient about the importance of exercise after knee surgery. When would be an appropriate time to do so? a. when the pain medication is working b. when the patient is talking about the stressors in her life c. when the family is present d. just before lunch when the patient is most awake

c. An increase in blood volume. **blood volume increases by approximately 40-50% during pregnancy. hematocrit decreases as a result of the increased blood volume.

The nurse recognizes that an expected change in the hematologic system that occurs during the 2nd trimester of pregnancy is: a. A decrease in WBC's b. Increase in hematocrit. c. An increase in blood volume. d. A decrease in sedimentation rate.

d. The amount of urine retained after voiding increases. **The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? a. The bladder distends and its capacity increases. b. Older adults ignore the need to void. c. Urine becomes more concentrated. d. The amount of urine retained after voiding increases.

secondary

The nurse recommends to a patient with diabetes to continue to do vision screens in order to monitor diabetic retinopathy. Which level of prevention is this? a. promotion b. tertiary c. primary d. secondary

b. orientation

The nurse sets a goal with her patient that she will get up and walk a lap around the unit at 3 times before the next shift arrives. Which stage of the helping relationship would this occur in? a. preinteraction b. orientation c. working d. termination

a. preinteraction

The nurse shows up to her shift early to make sure she is available to receive report on her patient and review her history (medical and nursing). Which stage of the helping relationship is this? a. preinteraction b. orientation c. working d. termination

d. a decrease in the ability to hear high-pitched sounds

The nurse suspects a pt has presbycusis when she says she has which of the following manifestations? a. ringing in the ears b. a sensation of fullness in the ears c. difficulty understanding the meaning of words d. a decrease in the ability to hear high-pitched sounds

b. Providing good eye contact c. Demonstrating a calm presence d. Spending time attentively with the patient

The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply) a. Matching the rate of speech to be the same as that of the patient b. Providing good eye contact c. Demonstrating a calm presence d. Spending time attentively with the patient e. Assuring the patient that all will be well

b. Prompts the patient to talk when he or she is ready c. Allows the patient time to think and gain insight

The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse's silence? (Select all that apply.) a. Allows the nurse time to focus and avoid saying the wrong thing b. Prompts the patient to talk when he or she is ready c. Allows the patient time to think and gain insight d. Allows time for the patient to drift off to sleep e. Determines whether the patient would prefer to talk with another staff member

c. "It sounds like you are afraid."

The nurse wants to use appropriate therapeutic communication when interacting with her client. Which of the following is an appropriate nursing statement? a. "Everything will be better in a few days." b. "I know what you are going through." c. "It sounds like you are afraid." d. "Just hang in there."

a. fluid restriction.

The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.

a. The students perception and learning is enhanced **With mild anxiety, the students perception and learning will be enhanced

The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of this level of anxiety? a. The students perception and learning is enhanced b. The students attention is focused solely on studying for the examination c. The students only topic of conversation is the examination d. The student cannot talk about the examination without crying

b. 1/2 tab

The order reads: Lanoxin 0.125 mg PO now. The medication is available in 0.25 mg tablets. Which of the following represent the number of tablets the nurse will give. a. 2 tab b. 1/2 tab c. 1 1/2 tab d. 1/4 tab

b. "Keep a night light on in your child's room"

The parent of a 4-year-old tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which nursing response is the most appropriate? a. "Let your child sleep in your bed with you" b. "Keep a night light on in your child's room" c. "Tell your child that monsters are not real" d. "Stay with your child until the child is asleep"

a. affective

The patient expresses his desire to know as much about management of the new diagnosis of diabetes. This is an example of which of the following domains of learning? a. affective b. psychomotor c. cognitive d. motivational

d. Sit down, touch and spend time with him.

The patient has been in contact isolation for 4 days because of a gastrointestinal infection. His ambulation is limited, and he has had few visitors. Nursing measures should include: a. Arrange for him to have a roommate b. Turn off the lights and pull the draperies c. Assist him in a chair and bring in a flower d. Sit down, touch and spend time with him.

c. psychomotor learning

The patient is concerned about learning how to change the ostomy that has been created. The nurse knows that the teaching strategies would focus on: a. affective learning b. motivational influences c. psychomotor learning d. cognitive learning

a. Tell me more about your concern. c. You are worried about your care?

The patient states, "I don't have confidence in my doctor. She looks so young." The nurse therapeutically responds: (Select all that apply.) a. Tell me more about your concern. b. You have nothing to worry about. Your doctor is perfectly competent. c. You are worried about your care? d. You can go online and see how others have rated your doctor. I do that. e. You should ask your doctor to tell you her background.

a. Hears better in a noisy environment

The patient who has conductive hearing loss.... a. Hears better in a noisy environment b. Hears sound but does not understand speech c. Often speaks loudly because his own voice seems low d. Experiences clearer sound with a hearing aid if the loss is less than 30 dB

d. Decrease the number of incontinence episodes.

The primary goal of nursing care for a client with stress incontinence is to: a. Help the client adjust to the frequent episodes of incontinence. b. Eliminate all episodes of incontinence. c. Prevent the development of urinary tract infections. d. Decrease the number of incontinence episodes.

a. develop topics for discussion which require problem-solving skills

The school nurse is teaching ninth graders about nutrition. What should the nurse do to achieve the best learning outcomes? a. develop topics for discussion which require problem-solving skills b. provide information through lecture c. complete and extensive literature search on eating disorders d. use simple words to promote understanding

c. endothelial cells

The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the _________________ in mom's body, which injures organs. a. spiral arteries b. epithelial cells c. endothelial cells d. juxtaglomerular cells

b. Offer ideas for ways to distract or redirect the patient d. Educate the spouse about the availability of adult day care as a respite e. Ask the spouse what she knows and has considered about dementia care options

The spouse of a male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select all that apply) a. Suggest that a long-term care facility be considered b. Offer ideas for ways to distract or redirect the patient c. Suggest that the spouse consult with the physician for anti-anxiety drugs d. Educate the spouse about the availability of adult day care as a respite e. Ask the spouse what she knows and has considered about dementia care options

b. The cardiovascular system

The student nurse is studying the changes a woman goes through during pregnancy. The student nurse knows that which body system undergoes the most dramatic changes during pregnancy? a. The skin b. The cardiovascular system c. The urinary system d. The gastrointestinal system

a. Previous experiences with grief and loss b. Religious affiliation and denomination c. Ethnic background and cultural practices

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply) a. Previous experiences with grief and loss b. Religious affiliation and denomination c. Ethnic background and cultural practices d. Current financial status e. Current medications

c. intermittent prone positioning **elevating = contracture

To prevent contracture in an amputation patient, what should the nurse do? a. elevate the stump b. massage the surrounding area c. intermittent prone positioning d. ice the wound

c. Cognitive changes secondary to cerebral ischemia

Vascular dementia is associated with which of the following? a. Transient ischemic attacks b. Bacterial or viral infection of neuronal tissue c. Cognitive changes secondary to cerebral ischemia d. Abrupt changes in cognitive function that are irreversible.

b. sedation **while these are all side effects of opioids, sedation is what alerts the nurse that the patient might begin to experience a lower respiratory rate

What almost always precedes respiratory depression when administering an opioid? a. constipation b. sedation c. myoclonus d. urinary retention

b. allergies **due to presentation of painful and watery eyes, ptosis, and symptoms of conjunctivitis

What are cluster headaches often confused with? a. diabetes b. allergies c. congestion d. tension headaches

b. Changing positions help alleviate contraction pain d. Fetal station is -5 e. Contractions are unpredictable

What are some characteristics of contractions associated with false labor? (Select all that apply) a. Contractions are 5 minutes apart that last for 1 minute and have been occurring for 1 hour b. Changing positions help alleviate contraction pain c. Cervix dilates from 2-5 cm d. Fetal station is -5 e. Contractions are unpredictable

b. Hydrocodone/acetaminophen (Norco) c. Acetaminophen with codeine (Tylenol #3)

What are some medications commonly used for moderate pain control in the postpartum period? (Select all that apply) a. Ibuprofen and Tylenol ES b. Hydrocodone/acetaminophen (Norco) c. Acetaminophen with codeine (Tylenol #3) d. Oxycodone/Acetaminophen (Percocet)

a. urine culture and sensitivity b. blood work (WBC count) d. imaging

What are the diagnostic methods used for pyelonephritis? (Select all that apply) a. urine culture and sensitivity b. blood work (WBC count) c. urine pH test d. imaging e. urine specific gravity test

a. care-related b. client-related d. system-related **quality-related refers to an actual outcome, not a variance that can affect the outcome (ex: a care-related factor can affect a quality-related outcome)

What are the types of variances that might inhibit us from meeting SMART outcomes? (Select all that apply) a. care-related b. client-related c. quality-related d. system-related

a. infection

What circumstance usually warrants an open amputation? a. infection b. lower extremity amputation c. amputation due to a traumatic injury d. upper extremity amputation

b. Normal saline

What is a common name for the IV solution 0.9% NaCl? a. Half normal saline b. Normal saline c. Lactated ringer's d. Sodium lactate

d. Pulselessness

What is a late sign of compartment syndrome? a. Paralysis b. Pain c. Parethesia d. Pulselessness

c. unrelieved pain

What is the #1 sign of compartment syndrome? a. pulselessness b. paresthesias c. unrelieved pain d. paralysis

a. alcohol

What is the ONLY dietary trigger for a cluster headache? a. alcohol b. sugar c. caffeine d. chocolate

d. have the patient state his or her name and birth date.

What is the best way for the nurse to make sure that the right patient is receiving a prescribed drug when the patient is alert and oriented? a. ask the patient to state his or her name b. check the patient's wrist band c. look at the patients chart d. have the patient state his or her name and birth date.

b. neurologic dysfunction

What is the cause of reflex incontinence? a. overactive bladder b. neurologic dysfunction c. inability to reach the toilet d. physical exertion

a. their health history

What is the key to determining the type of headache someone is experiencing? a. their health history b. their medication list c. objective data d. past surgeries/treatments

d. Measure from the symphysis pubis notch to the top of fundus

What is the method of measuring a pregnant patient's fundus? a. Measure from the symphysis pubis to the umbilicus b. Measure across the abdomen laterally c. A pelvimeter is used to measure fundal height d. Measure from the symphysis pubis notch to the top of fundus

a. weight gain

What is the most consistent manifestation of fluid volume excess (hypervolemia)? a. weight gain b. weight loss c. cardiac dysrhythmias d. dyspnea

c. 20-45 years old

What is the typical onset of age for cluster headaches? a. 20-30 years old b. 18-25 years old c. 20-45 years old d. 25-40 years old

a. tie his own shoes

What should the nurse NOT encourage the patient to do after hip fracture surgery? a. tie his own shoes b. cough c. deep breathe d. get up and walk around

a. Maintain regular bowel elimination. d. Cleanse the perineum from front to back. **D is wrong because that is teaching for someone with incontinence, not UTIs

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) a. Maintain regular bowel elimination. b. Limit water intake to 1 to 2 glasses a day. c. Cleanse the perineum from front to back. d. Practice pelvic muscle exercise (Kegel) daily.

b. The transition phase is the longest phase of stage 1 and contractions are very intense and long in duration. **transition phase is the SHORTEST

What statement is FALSE about the transition phase of stage 1 of labor? a. The mother may experience intense pain, irritation, nausea, and deep concentration. b. The transition phase is the longest phase of stage 1 and contractions are very intense and long in duration. c. The cervix will dilate from 8 to 10 cm. d. The transition phase ends and progresses to stage 2 of labor when the cervix has dilated to 10 cm.

c. unilateral eyelid swelling

When a patient is experiencing a cluster headache, the nurse will plan to assess for which of the following? a. nuchal rigidity b. projectile vomiting c. unilateral eyelid swelling d. throbbing, bilateral facial pain

b. Pulmonary Edema

When administering a hypertonic solution, the nurse should closely watch for which of the following? a. Signs of dehydration b. Pulmonary Edema c. Fluid volume deficient d. Increased Lactate level

c. Choose a place without distracting stimuli

When administering a mental status examination to a patient with delirium, the nurse should do which of the following? a. Wait until the patient is well-rested b. Administer an anxiolytic medication c. Choose a place without distracting stimuli d. Reorient the patient during the examination

d. All of the above

When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include: a. Water gain b. Diuretic therapy c. Diaphoresis d. All of the above

a. Bounding pulse

When assessing a patient for signs of fluid overload, the nurse would expect to observe: a. Bounding pulse b. Flat neck veins c. Poor skin turgor d. Weak pulse

b. "How would you describe your pain?"

When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient's pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How much medication do you take for the pain?" d."How many times a day do you medicate for pain?"

a. A client in pain

When gathering data to assist with assessments of clients, you will find which of the following clients most at risk for sensory overload? a. A client in pain b. A homebound client c. A client on bed rest d. A client in isolation

b. in an emergency situation such as a cardiac arrest

When is it acceptable for the nurse to take a verbal order from the prescriber before giving a drug to a patient? a. during the night shift when the prescriber is not at the hospital b. in an emergency situation such as a cardiac arrest c. when a patient is experiencing severe pain d. at any time it is necessary

a. Induction of labor b. Augmentation of labor d. After delivery of the placenta

When is oxytocin/pitocin used during the labor and delivery process? (Select all that apply) a. Induction of labor b. Augmentation of labor c. Cervical ripening d. After delivery of the placenta

d. All of the above

When is oxytocin/pitocin used during the labor and delivery process? (Select all that apply) a. Induction of labor b. Augmentation of labor c. After delivery of the placenta d. All of the above

b. Losing sense of time c. Difficulty performing familiar tasks d. Becoming lost in a usually familiar environment

When providing community health care teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply) a. Misplacing car keys b. Losing sense of time c. Difficulty performing familiar tasks d. Becoming lost in a usually familiar environment

d. A stage 1 pressure injury

When repositioning an immobile patient, the nurse notices skin that is red and intact over the hip bone. What is indicated when a reddened area is unblanchable on fingertip touch? a. A local skin infection b. Sensitive skin c. A stage 3 pressure injury d. A stage 1 pressure injury

c. at the first indication of active bowel sounds

When should you advance a patient's diet after surgery? a. when they mobilize for the first time post-op b. after they urinate for the first time post-op c. at the first indication of active bowel sounds d. as soon as they wake up from anesthesia

b. "I have had generalized pain throughout my body for at least 3 to 4​ months."

When taking a health​ history, which statement from the client would support a diagnosis of​ fibromyalgia? a. ​"I have experienced persistent pain in my​ knees, ankles, and​ feet."​ b. "I have had generalized pain throughout my body for at least 3 to 4​ months." c. ​"My joints are stiff when I get up in the​ mornings."​ d. "I have experienced heart palpitations and a fluttering sensation for the past few​ weeks."

a. Holistic

When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? a. Holistic b. Health belief c. Transtheoretical d. Health promotion

b. Decrease in blood flow to the nerves of the feet

When teaching a patient about rest pain with PAD, what should the nurse explain as the cause of the pain? a. Vasospasm of cutaneous arteries in the feet b. Decrease in blood flow to the nerves of the feet c. Increase in retrograde venous perfusion to the lower legs d. Constriction in blood flow to leg muscles during exercise

b. TENS works peripherally and centrally on nerve receptors. d. Placing electrodes directly over or near the pain site works best.

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which of the following represents an accurate description of the non-pharmacological therapy? (Select all that apply.) a. Turn TENS on before patient feels discomfort. b. TENS works peripherally and centrally on nerve receptors. c. TENS does not require a health care provider order. d. Placing electrodes directly over or near the pain site works best.

a. Apply ice using firm pressure over the skin. b. Apply ice for 5 minutes or until numbness occurs. e. Use a slow, circular steady massage.

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) a. Apply ice using firm pressure over the skin. b. Apply ice for 5 minutes or until numbness occurs. c. Apply ice no more than 3 times a day. d. Limit application of ice to no longer than 10 minutes. e. Use a slow, circular steady massage.

a. Check for needed adaptive equipment. c. Give the patient time to respond to questions. d. Keep communication short and to the point.

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply) a. Check for needed adaptive equipment. b. Exaggerate lip movements to help the patient lip-read. c. Give the patient time to respond to questions. d. Keep communication short and to the point. e. Communicate only through written information.

b. area surrounding muscle

Where in the body does compartment syndrome occur? a. interstitial space b. area surrounding muscle c. joints d. vascular system

a. High low-density lipoprotein cholesterol (LDL-C) b. Smoking d. Type 2 diabetes **Having an LDL-C value of less than 100 mg/dL is optimal. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply) a. High low-density lipoprotein cholesterol (LDL-C) b. Smoking c. Aspirin consumption d. Type 2 diabetes e. Vegetarian diet

c. Fullness of neck veins when supine

Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? a. Dryness of mucous membranes b. Skin turgor c. Fullness of neck veins when supine d. Fullness of neck veins when upright

c. Presumptive Signs

Which category of pregnancy signs are subjective and can only be reported by the patient? a. Positive Signs b. Probable Signs c. Presumptive Signs d. Proven Signs

d. An 80-year-old client admitted for emergency surgery

Which client is at greatest risk for experiencing sensory overload? a. A 40-year-old client in isolation with no family to visit b. A 28-year-old quadriplegic client in a private room c. A 16-year-old listening to loud music d. An 80-year-old client admitted for emergency surgery

c. premonitory symptoms **NO premonitory symptoms or aura with this type

Which clinical manifestation is NOT accurate regarding a tension type headache? a. bilateral pain b. photophobia and phonophobia present c. premonitory symptoms d. tightening pain

c. "The pain disturbs my sleep at night." **Cluster headaches usually occur at night and causes sleep disturbances.

Which complaint made by the patient indicates that the individual may be suffering from a cluster headache? a. "The pain is constant." b. "The pain is followed by nausea." c. "The pain disturbs my sleep at night." d. "The pain lasts for longer than eight hours.

d. Sodium

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid? a. Potassium b. Magnesium c. Calcium d. Sodium

c. Palpation of tenderness points **this is a finding relevant to fibromyalgia patients

Which element is included in the focused physical examination portion of the nursing assessment of the client with​ fibromyalgia? a. Pattern of fatigue b. Symptom severity scale c. Palpation of tenderness points d. Duration of pain

a. Absence of pain or pressure

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? a. Absence of pain or pressure b. Blurred vision in the morning c. Seeing colored halos around lights d. Eye pain accompanied with nausea and vomiting

c. Hypertension is usually asymptomatic until significant organ damage occurs

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Dietary sodium restriction will control BP for most patients b. Most patients are able to control BP through lifestyle changes c. Hypertension is usually asymptomatic until significant organ damage occurs d. Annual BP checks are needed to monitor treatment effectiveness

a. Overuse of joints from sports or strenuous activities b. Obesity d. Activities affecting​ weight-bearing joints **C is a risk factor for gout

Which is a common risk factor for​ osteoarthritis? (Select all that​ apply) a. Overuse of joints from sports or strenuous activities b. Obesity c. Ingestion of large amounts of purine d. Activities affecting​ weight-bearing joints

b. Determining the content and feeling of the client's message

Which is the nurse doing when using the interviewing technique of "attentive listening"? a. Identifying the client's concerns and exploring them with "why" questions b. Determining the content and feeling of the client's message c. Employing silence to encourage the client to talk d. Using verbal skills to obtain information

b. setting realistic goals which have high priority for the patient

Which is the priority patient teaching strategy when limited time is available for teaching? a. observing more experienced nurse educators to learn how to teach faster and more efficiently b. setting realistic goals which have high priority for the patient c. providing reading materials for the patient instead of discussions d. referring the patient to a nurse educator in private practice for teaching

d. NSAIDs **

Which medication (class) is NOT used during preventative drug therapy for migraines? a. Botox b. Antiseizure drugs c. SSRIs d. NSAIDs

a. Have the patient record dietary intake for 3 days **The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day food diary

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Have the patient record dietary intake for 3 days b. Give the patient a detailed list of low-sodium foods c. Teach the patient about foods that are high in sodium d. Help the patient make an appointment with a dietitian

a. using an open posture c. establishing and maintaining eye contact e. sitting facing the client **Choice D is wrong because nodding can be misinterpreted as the nurse agreeing with what the client is saying, instead of the nurse meaning to hint to the client that she is understanding what she is saying

Which of the following actions should the nurse take when demonstrating empathic presence to a client? (Select all that apply) a. using an open posture b. writing down what the patient says to avoid forgetting details c. establishing and maintaining eye contact d. nodding in agreement with the client throughout the conversation e. sitting facing the client

b. blood clots c. infection d. compartment syndrome

Which of the following are complications of a fracture? (Select all that apply) a. acute delirium b. blood clots c. infection d. compartment syndrome e. hip flexion contracture

a. focusing on the nurse rather than the client b. changing the subject c. making value judgements d. giving advice

Which of the following are examples of a nurse using nontherapeutic communication techniques? (Select all that apply) a. focusing on the nurse rather than the client b. changing the subject c. making value judgements d. giving advice e. seeking clarification

b. The client's history of three full-term pregnancies. **loss of pelvic muscle strength

Which of the following assessment data would most likely be related to a client's current complaint of stress incontinence? a. The client's intake of 2 to 3 L of fluid per day. b. The client's history of three full-term pregnancies. c. The client's age of 45 years. d. The client's history of competitive swimming.

b. intermittent catheterization

Which of the following care management strategies for patients with urge incontinence is NOT effective? a. urge inhibition exercises b. intermittent catheterization c. pelvic muscle training d. avoiding irritants

c. Catheters

Which of the following causes the majority of UTI's in hospitalized patients? a. Lack of fluid intake b. Inadequate perineal care c. Catheters d. Immunosuppression

d. hyperkalemia **contraindicated with hyperkalemia and lactic acidosis

Which of the following conditions is contraindicated with the administration of Lactated Ringer's? a. hypokalemia b. hypercalcemia c. hypermagnesemia d. hyperkalemia

b. hypocalcemia c. hypokalemia

Which of the following electrolytes imbalances are often seen in conjunction with hypomagnesemia? (Select all that apply) a. hypernatremia b. hypocalcemia c. hypokalemia d. hypercalcemia

a. Forceps left in an abdominal cavity b. Patient fall, with injury d. Administration of morphine overdose e. Death of patient related to postpartum hemorrhage **Sentinel events are serious, unexpected occurrences involving death or physical or psychological harm

Which of the following examples can be considered sentinel events? (Select all that apply) a. Forceps left in an abdominal cavity b. Patient fall, with injury c. Short staffing d. Administration of morphine overdose e. Death of patient related to postpartum hemorrhage

d. Nurse Lee is professionally threatened by Nurse Doe

Which of the following examples display interpersonal conflict? a. Nurses on the day and night shift are conflicting regarding who should do client daily weights b. Nurses throughout the hospital disagree on having 8 or 12 hour shifts c. Nurse Jones is deciding between going to a professional meeting or attending a play d. Nurse Lee is professionally threatened by Nurse Doe

c. red meat **this is more associated with gout, and is to be avoided in those with gout

Which of the following foods is NOT known to be a trigger of migraine headaches? a. cheese b. chocolate c. red meat d. foods containing MSG

d. rice **no organ meat, red meat, shellfish, alcohol (purines)

Which of the following foods/beverages would be the BEST choice for someone with gout? a. cheeseburger b. shrimp c. martini d. rice

b. Use an electronic drawing screen allowing the client to create pictures during an assessment

Which of the following illustrates the use of technology to improve communication with a client who is cognitively impaired? a. Provide the client with an online video as a teaching aid that allows multiple viewings b. Use an electronic drawing screen allowing the client to create pictures during an assessment c. Offer translation software for the client

a. Have the client urinate on a timed schedule

Which of the following interventions would be most appropriate for a client who has urge incontinence? a. Have the client urinate on a timed schedule. b. Provide a bedside commode. c. Teach the client intermittent self-catheterization technique.

a. high blood pressure

Which of the following is NOT considered a clinical manifestation of fibromyalgia? a. high blood pressure b. non-refreshing sleep c. increased urine frequency and urgency d. fatigue

a. Positive pregnancy test

Which of the following is NOT considered presumptive signs of pregnancy? a. Positive pregnancy test b. Amenorrhea c. Increased urination d. Quickening

d. temperature **NV assessment includes sensation, movement, paresthesias, cap refill. pulses, affected extremities, mobility

Which of the following is NOT included in a neurovascular assessment? a. capillary refill b. sensation c. pulses d. temperature

a. Anger **Anger is a psychological response to grief. Insomnia and decreased appetite are biological responses to grief. Personality changes are a behavioral response to grief.

Which of the following is a psychological response to​ grief? a. Anger b. Personality changes c. Insomnia d. Decreased appetite

c. hyperactive bowel sounds

Which of the following is a symptom consistent with dumping syndrome? a. tachycardia b. weak pulse c. hyperactive bowel sounds d. confusion

c. the ability to achieve and maintain high standards of care d. access to standard plans of care for many health problems e. improved communication of the patient's health status to the health care team

Which of the following is an advantage of using informatics in healthcare delivery? Select all that apply. a. reduced need for nurses in acute care b. prevention of HIPAA violations c. the ability to achieve and maintain high standards of care d. access to standard plans of care for many health problems e. improved communication of the patient's health status to the health care team

a. fluid replacement therapy **going from symptomatic to asymptomatic

Which of the following is an example of a health restoration strategy? a. fluid replacement therapy b. immunizations c. vision/hearing screenings d. hand hygiene

a. "Are you going to group therapy tomorrow?" b. "How long have you been depressed?" d. "Do you not want to take your medication?" e. "Do you have a family history of depression?"

Which of the following is an example of closed-ended questioning? (Select all that apply) a. "Are you going to group therapy tomorrow?" b. "How long have you been depressed?" c. "Tell me about your concern" d. "Do you not want to take your medication?" e. "Do you have a family history of depression?"

b. Administering calcium gluconate

Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia? a. Administering calcitonin b. Administering calcium gluconate c. Administering loop diuretics d. Encouraging ambulation

c. Handwashing

Which of the following is the first priority in preventing infections when providing care for a client? a. Wearing gowns and goggles b. Using a barrier between client's furniture and nurse's bag c. Handwashing d. Wearing gloves

b. To shape the residual limb **figure 8 shape can help reform the stump

Which of the following is the reason a compression dressing or a cast is applied after amputation? a. To reduce pain b. To shape the residual limb c. To prevent wound contamination d. to prevent stimulation of nerve endings

c. Cervidil **used for cervical ripening

Which of the following medications is NOT used to manage postpartum bleeding? a. Pitocin b. Misoprostol c. Cervidil d. Methergine e. Carboprost (Hemabate)

a. low anxiety

Which of the following patient characteristics enhances the person's learning? a. low anxiety b. high self-efficacy c. being able to laugh about the current health problem d. thinking about the need to change

d. Katie, a 4-year-old **head circumference stops getting checked after 3 years

Which of the following patients will not have their head circumference checked at their health supervision visit? a. Lucy, a 9-month-old b. Benjamin, a 2-year-old c. Jack, a 1-year-old d. Katie, a 4-year-old

b. A patient describes how to set up a pill organizer for newly ordered medicines. d. A patient demonstrates how to take his blood pressure at home.

Which of the following scenarios demonstrate that learning has taken place? (Select all that apply.) a. A patient listens to a nurse's review of the warning signs of a stroke. b. A patient describes how to set up a pill organizer for newly ordered medicines. c. A patient attends a spinal cord injury support group. d. A patient demonstrates how to take his blood pressure at home. e. A patient reviews written information about resources for cancer survivors.

b. the nurse's opinion on what went wrong **incidence reports should only consist of objective data (time, location, patient's condition, treatment and response, who was involved, etc.)

Which of the following should NOT be included in an incidence report? a. nurses that were involved b. the nurse's opinion on what went wrong c. patient's condition d. the time and location of the incident

a. Materials should be culturally diverse b. Information must be accurate and current c. Materials should be written in the clients spoken language e. Materials should be distributed to the client in advance

Which of the following should the nurse consider when selecting written educational materials for a client who is scheduled for a procedure the next day? (Select all that apply) a. Materials should be culturally diverse b. Information must be accurate and current c. Materials should be written in the clients spoken language d. Materials should be written at the eighth grade level e. Materials should be distributed to the client in advance

a. noise level b. size of space c. lighting e. temperature **pain level is incorrect. The nurse should ensure that the client's pain level is addressed prior to teaching, but this factor does not affect the teaching environment.

Which of the following should the nurse take into consideration when selecting an environment to provide client education? (Select all that apply) a. noise level b. size of space c. lighting d. pain level e. temperature

b. Difficulty arousing the patient

Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? a. Oxygen saturation of 95% b. Difficulty arousing the patient c. Respiratory rate of 12 breaths/min d. Pain intensity rating of 5 on a scale of 0 to 10

b. Meconium can cause infection during the birth process d. The foramen ovale is a hole between the right and left atria

Which of the following statements are correct? (Select all that apply) a. The neonatal period includes the first 2 years b. Meconium can cause infection during the birth process c. The ductus arteriosus connects the right and left atria d. The foramen ovale is a hole between the right and left atria

c. "Tell me about your relationship with your wife"

Which of the following statements is an example of a therapeutic communication technique? a. "I would not be concerned about that" b. "Why did you not go to your scheduled group therapy?" c. "Tell me about your relationship with your wife" d. "I'm sure it'll all turn out okay in the end"

a. Embedded medication alerts for side effects in the EHR b. Immediate access to digital x-rays c. Use of phones that connect directly to an assigned nurse for clients d. Integration of telehealth to follow up with clients in rural locations

Which of the following support the integration of informatics into nursing practice to support safety in client care? (Select all that apply) a. Embedded medication alerts for side effects in the EHR b. Immediate access to digital x-rays c. Use of phones that connect directly to an assigned nurse for clients d. Integration of telehealth to follow up with clients in rural locations e. Wireless internet access for clients from the health care facility

a. reassurance b. lecturing c. giving advice d. changing the subject e. asking "why" questions

Which of the following techniques is considered a non-therapeutic technique of communication regarding the nurse-patient relationship? (Select all that apply) a. reassurance b. lecturing c. giving advice d. changing the subject e. asking "why" questions

a. hips d. knees **B is a common site for pressure injuries, C is common for gout

Which parts of the body are most commonly affected by osteoarthritis? (Select all that apply) a. hips b. sacrum c. big toe d. knees

a. A patient with a sodium level of 155 mEq/L

Which patient below is considered hypernatremic? a. A patient with a sodium level of 155 mEq/L b. A patient with a sodium level of 145 mEq/L c. A patient with a sodium level of 120 mEq/L d. A patient with a sodium level of 136 mEq/L

c. Cloudy, hazy vision

Which patient finding below is associated with the development of cataracts? a. Loss of central vision b. Loss of peripheral vision c. Cloudy, hazy vision d. Black spots in vision

c. A 50 y.o. postmenopausal woman **Women are more prone to UTIs after menopause due to reduced estrogen levels

Which patient is at greatest risk for developing a urinary tract infection (UTI)? a. A 35 y.o. woman with a fractured wrist b. A 20 y.o. woman with asthma c. A 50 y.o. postmenopausal woman d. A 28 y.o. with angina

c. 42-year-old woman with systemic lupus erythematosus and renal failure **renal failure was the clue

Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β- adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection

d. A 78-year-old man admitted to the medical unit with complications related to heart failure **Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure)

Which patient is most at risk for developing delirium? a. A 50-year-old woman with cholecystitis b. A 19-year-old man with a fractured femur c. A 42-year-old woman having an elective hysterectomy d. A 78-year-old man admitted to the medical unit with complications related to heart failure

a. a patient with Parkinson's **B would be at risk for stress incontinence, C at risk for reflex incontinence, and D at risk for functional incontinence

Which patient population is an an increased risk of urge incontinence? a. a patient with Parkinson's b. a pregnant patient c. a patient with a spinal cord injury d. a patient with a knee amputation

a. An older man confined to bed at home after a stroke

Which patient would a nurse assess as being at greatest risk for sensory deprivation? a. An older man confined to bed at home after a stroke b. An adolescent in an oncology unit working on homework supplied by friends c. A woman in labor d. A toddler in a playroom awaiting same-day surgery

c. "In fetal circulation the pulmonary artery and aorta are connected via the ductus arteriosus."

Which statement below accurately describes the role of the ductus arteriosus in a fetus? a. "The ductus arteriosus helps connect the umbilical artery to the inferior vena cava." b. "The ductus arteriosus is found between the right and left atrium." c. "In fetal circulation the pulmonary artery and aorta are connected via the ductus arteriosus." d. "The ductus arteriosus only carries oxygenated blood from the left side of the heart to the right side."

b. "My pain is so severe that it hurts to stretch or elevate my arm."

Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to notify the physician immediately? a. "It is really itchy inside my cast!" b. "My pain is so severe that it hurts to stretch or elevate my arm." c. "I can feel my fingers and move them." d. "I've been using ice packs to reduce swelling.""

a. Collaboration between staff members from sending and receiving departments c. Using a standardized transfer policy and transfer tool

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) a. Collaboration between staff members from sending and receiving departments b. Requiring that the patient visit the facility before a transfer is arranged c. Using a standardized transfer policy and transfer tool d. Arranging all patient transfers during the same time each day e. Relying on family members to share information with the new facility

b. Speak normally and slowly e. Write out names or difficult words

Which strategies would best assist the nurse in communicating with a pt who has hearing loss? (Select all that apply) a. Overenunciate speech b. Speak normally and slowly c. Exaggerate facial expressions d. Raise the voice to a higher pitch e. Write out names or difficult words

c. "Walk to the point of leg pain, then rest, resuming when pain stops." **Exercise may improve arterial blood flow. Application of heat should be avoided in clients with PAD owing to lack of sensation and possible burns

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? a. "Elevate your legs above heart level to prevent swelling." b. "Inspect your legs daily for brownish discoloration around the ankles." c. "Walk to the point of leg pain, then rest, resuming when pain stops." d. "Apply a heating pad to the legs if they feel cold."

c. standing up

Which technique is the most accurate way to take someone's weight? a. after dinner b. laying in bed c. standing up d. before they go to the bathroom

c. tension type headache

Which type of headache has a bilateral presentation? a. cluster headache b. migraines headache c. tension type headache d. sinus headache

c. reflex

Which type of incontinence, if left unaddressed, could lead to autonomic dysreflexia? a. urge b. stress c. reflex d. transient

d. burning **phantom limb pain is NEUROPATHIC, which is typically described as burning, shooting, stinging, etc.

Which word might a patient use to describe phantom limb pain? a. cramping b. squeezing c. dull d. burning

b. Itching c. Burning d. Shooting

Which words are most likely to be used to describe neuropathic pain (Select all that apply)? a. Dull b. Itching c. Burning d. Shooting

a. Discontinue the existing IV

While assessing a client who is receiving IV therapy via his left forearm, the nurse notes that the site is red, swollen, and painful, and that the surrounding tissues are hard. The nurse's first action should be which of the following? a. Discontinue the existing IV b. Initiate a new IV line in another extremity c. Apply a hot pack to the irritated site d. Determine if the client continues to need IV therapy

b. dying wife

While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preference concerning end-of-life care for the dying wife? a. a priest b. dying wife c. hospice staff d. husband of dying wife

a. Give the client a written record of his BP to bring to his provider

While participating in a community health fair, a nurse is providing information to a client who has a BP of 150/90 mmHg during screening. Which of the following actions should the nurse take? a. Give the client a written record of his BP to bring to his provider b. Encourage the client to go to the nearest emergency department c. Instruct the client to follow-up with a provider within 6 months d. Explain to the client that he is not at risk unless he has manifestations of HTN

b. Deep-tissue injury

While performing a skin assessment on a patient who is immobile, you note a purplish black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this may be? a. Stage 1 pressure injury b. Deep-tissue injury c. Stage 4 pressure injury d. Stage 2 pressure injury

a. Impaired tissue perfusion

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? a. Impaired tissue perfusion b. Alteration in body image c. Alteration in activity tolerance d. Impaired skin integrity

a. The father goes through three phases of acceptance of his own

With regard to the father's acceptance of the pregnancy and preparation for childbirth, the maternity nurse should know which of the following? a. The father goes through three phases of acceptance of his own b. The father's attachment to the fetus cannot be as strong as that of the mother because it does not start until after birth c. In the last 2 months of pregnancy, most expectant fathers suddenly get very protective of their established lifestyle and resist making changes to the home d. Typically, men remain ambivalent about fatherhood right up to the birth of their child

b. Crying increases the distribution of air in the lungs

With regard to the respiratory development of the newborn, nurses should be aware of which of the following? a. Surfactant increases surface tension and pressure required to keep the alveoli open b. Crying increases the distribution of air in the lungs c. Newborns are instinctive mouth breathers d. Seesaw respirations are no cause for concern in the first hour after birth

c. Explain procedures to client, and talk as if client can hear

You are about to bathe an unconscious client. Which of the following interventions are most important on your part? a. Vary the schedule of bathing and care from day to day b. Tune the radio to client's favorite music during bath time c. Explain procedures to client, and talk as if client can hear d. Speak louder to the client than to other clients

a. Call the nursing supervisor to discuss the situation.

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? a. Call the nursing supervisor to discuss the situation. b. Discuss the problem with a colleague. c. Leave the nursing unit and go home. d. Say nothing and begin your work.

c. Many nurses have called in sick during the past two weeks

You are the new nurse on a busy cardiac ICU. Your unit has experienced more than 8 deaths in the past month. Which of the following behaviors suggests that you and the nurses are in need of some grief counseling or support? a. Everyone is helping each other with daily tasks and care on the unit b. The unit's 'Thank You' board has had an increase in the number of messages posted during the past week c. Many nurses have called in sick during the past two weeks d. The nurses have taken turns covering each other so that the primary nurse could attend the patient's funeral, if desired

b. "It burns when I pee."

You have a patient that might have a urinary tract infection (UTI). Which statement by the patient suggests that a UTI is likely? a. "I pee a lot." b. "It burns when I pee." c. "I go hours without the urge to pee." d. "My pee smells sweet."

c. The infant smiles at its parent

You're assessing a 2-month-old infant. Which finding below is a normal milestone that should be reached by this infant at this age? a. The infant can sit up with support b. The infant holds a rattle c. The infant smiles at its parent d. The infant is afraid of strangers

a. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." c. "It hurts to elevate my legs." d. "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away." **B is a sign of CVI/PVD

You're assessing a patient's health history for peripheral vascular disease. What signs and symptoms reported by the patient would indicate the patient may be experiencing peripheral arterial disease? (Select all that apply) a. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." b. "If I stand or sit too long my legs start to feel heavy and achy." c. "It hurts to elevate my legs." d. "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."

d. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence. **bowel incontinence increases the risk of a UTI due to the anatomy of the female (short urethra) and the close proximity between the rectum to the urethra.

You're assessing your patients during morning rounding. Which patient below is at MOST risk for developing a urinary tract infection? a. A 25 year old patient who finished a regime of antibiotics for strep throat 10 weeks ago. b. A 55 year old female who is post-opt day 7 from hip surgery. c. A 68 year old male who is experiencing nausea and vomiting. d. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence.

a. Encourage fluid intake of 2-3 liter per day d. Apply alternating cold and warm compresses to right foot as tolerated by the patient daily

You're developing a nursing care plan for a patient with gout present in the right foot. What specific nursing interventions will you include in this patient's plan of care? (Select all that apply) a. Encourage fluid intake of 2-3 liter per day b. Provide patient with foods high in purine with each meal daily c. Administer PRN dose of Aspirin for a pain rating greater than 5 on 1-10 scale d. Apply alternating cold and warm compresses to right foot as tolerated by the patient daily

d. The patient places the drops of medication directly on the eye via the cornea **Eye drops are placed in the lower sac of the eye (conjunctival sac), NOT directly on the eye via the cornea

You're observing a patient self-administer eye drops for the treatment of glaucoma. Which finding below requires you to re-educate the patient on how to administer eye drops correctly? a. The patient refrains from blinking after instilling the eye drops b. The patient washes hands before and after administering the eye drops c. The patient uses a tissue to catch any medication that drips out of the eye after administration of the drops d. The patient places the drops of medication directly on the eye via the cornea

a. Perform fundal massage and assist the patient to the bathroom.

You're performing a routine assessment on a mother post-delivery. The uterus is soft and displaced to the left of the umbilicus. What is your next nursing action? a. Perform fundal massage and assist the patient to the bathroom. b. Continue to monitor the mother. This is a normal finding post-delivery. c. Notify the physician. d. Administer PRN dose of Pitocin as ordered by the physician.

a. "The best sleeping position for the baby is on their side or tummy". **The best sleeping position for the baby is on their BACK

You're teaching a new mom of a 1-week-old infant on how to prevent SIDS (Sudden Infant Death Syndrome). Which statement by the parent requires you to re-educate the parent on this topic? a. "The best sleeping position for the baby is on their side or tummy". b. "It's okay to share the same room with the baby." c. "I will stop swaddling the baby once he can roll over onto his tummy". d. "I will be sure to remove extra blankets and toys from the baby's bed."

a. Thick, tough d. Brown pigmented **B and C are PAD

Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? (Select all that apply) a. Thick, tough b. Thin, scaly c. Hairless d. Brown pigmented

b. At 28 weeks she should receive the Rh immune globulin.

Your patient has underwent testing of her blood type and Rh factor. She has A- blood type. Which of the following statement is correct? a. At 36 weeks she will receive Rh immune globulin. b. At 28 weeks she should receive the Rh immune globulin. c. No further testing will be done because the patient is Rh negative, instead of Rh positive. d. The patient will be checked for clotting problems.

a. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying

Your patient is 2 hours post-op from a cast placement on the right leg. The patient has family in the room. Which action by the significant other requires you to re-educate the patient and family about cast care? a. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying b. Elevating the cast above heart level with pillows c. Checking the color and temperature of the right foot d. Using a hair dryer on the cool setting to help with drying.