Exam Questions
A nurse is preparing to administer levothyroxine 0.176 mg PO daily. Amount available is 88 mcg/tab, how many tabs should be given?
2 tablets of levothyroxine
The health care provider prescribes vancomycin 850 mg in 100mL of 5% dextrose. Drug should be infused over 45 minutes. The drop factor of the IV tubing 15 drops/mL. At how many drops per minute will a nurse infused the medication
33 drops/ minute
An unmarried young woman describes her sex life as "active" and involving "many" partners. She wants a contraceptive method that is reliable and does not interfere with sex. She requests an intrauterine device (IUD). The nurse's most appropriate response is: A. "The risk of pelvic inflammatory disease (PID) will be higher for you" B. "The IUD will protect you from STIs" C. "Pregnancy rate are high with IUDs" D. "The IUD does not interfere with sex"
A. "The risk of pelvic inflammatory disease (PID) will be higher for you"
The nurse who provides care for a patient with primary dysmenorrhea should be aware that the optimal pharmacologic therapy for pain relief is: A. Aspirin B. oral contraceptives (OCPs) C. NSAIDs D. Acetaminophen
C. NSAIDs
A nurse caring for an adolescent with gonorrhea which drug to be ordered for treatment? A. penicillin G B. Tetracycline C. ceftriaxone D. acyclovir
C. ceftiaxone
A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Please go away now, no one can help me" How should the nurse respond? a. "I will come back later and we can talk" b. "Why are you crying?" c. "Do you think crying will help?" d. "Everything will be OK"
a. "I will come back later and we can talk"
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. Contractions are 5-9 min apart, 20-30 seconds in duration, and mild intensity. Cervical dilation is 1-2 cm and uneffaced. Membranes are intact. The nurse should expect the women to be: a. admitted for extended observation b. discharged home with sedative c. discharged home to await onset of labor d. admitted and prepared fro c-section
d. admitted and prepared fro c-section
A client who has generalize anxiety disorder is attending group therapy. During the group meeting, the nurse facilitator asks each member to identify one goal for the day. When it is the client's turn, he doesn't respond. What action the nurse take? a. often the client a suggestion b. instruct the client to give a response c. move on to the next client d. allow the client time to collect their thoughts
d. allow the client time to collect their thoughts
A nurse is caring for a client who is primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not" Which of the following should the nurse recognize as signs of true labor? a. station of presenting part b. rupture of membranes c. preterm contractions d. changes in cervix
d. changes in cervix
A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? a. "This will occur between the fourth and fifth months of pregnancy" b. "This will happen by the end of the first trimester of pregnancy" c. "This will happen once the uterus begins to rise out the pelvis" d. "This will occur during the last trimester of pregnancy"
a. "This will occur between the fourth and fifth months of pregnancy"
A nurse is assessing a client who has myasthenia gravis. Which client statement indicates to the nurse that the client needs a referral for OT? a. "I have a hard time holding a fork and spoon" b. "I have been having trouble with bowel control" c. "I would prefer to get around the house in a wheelchair, rather than a walker" d. "its hard for me to swallow"
a. "I have a hard time holding a fork and spoon"
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide" b. "Surfactant is used to reduce episodes of periodic apnea" c. "The drug keeps your baby from requiring too much sedation" d. "Your baby needs this medication to fight a possible respiratory tract infection"
a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide"
A nurse is reinforcing teaching about ALS with newly diagnosed client and family. Which is nursing statement is appropriate? a. "This is a progressive disease that gradually results in paralysis that is permanent" b. "It is important to consider advanced directives now because cognitive function decreases as disease progresses" c. "ALS results from excess chemical in the brain, and the symptoms can be controlled with medication" d. "Most people recover from ALS with treatment, though symptoms can be severe"
a. "This is a progressive disease that gradually results in paralysis that is permanent"
Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurological care inpatient unit for the past week? a. 68 yr old with weakness in extremities due to ALS b. 56 yr old client with Gullian-Barre syndrome experiencing orthopnea c. 34 yr old client with new diagnosis of myasthenia gravis d. 25 yr old just admitted with a C4 spinal cord injury
a. 68 yr old with weakness in extremities due to ALS
When providing education to a patient about adverse effects of Depo-Provera, the nurse should include which of the following in her teaching plan? a. Decreased bone density b. weight loss c. Type II diabetes d. Type I diabetes
a. Decreased bone density
A nurse is caring for a client who is 36 weeks of gestation and who has suspected placenta previa. Which of the following findings support this diagnosis? a. Painless red vaginal bleeding b. Increasing abdominal pain with a non relaxed uterus c. Abdominal pain with scant red vaginal bleeding d. Intermittent abdominal pain following passage of bloody mucus
a. Painless red vaginal bleeding
A nurse is talking with a newly admitted client. Which of the following indicates transference behavior? a. accuses the nurse telling them what to do just like their former spouse b. reminds the nurse of a friend who died several months ago from a drug overdose c. is asked to go out to dinner by the nurse d. become angry at the nurse and threatens to self harm
a. accuses the nurse telling them what to do just like their former spouse
A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely has: a. Amenorrhea b. Positive pregnancy test c. Chadwick sign d. Hegar sign
a. amenorrhea
A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? a. an intrauterine device b. an oral contraceptive c. a male condom d. a diaphragm with spermicide
a. an intrauterine device
SATA: What teaching should a nurse provide to a client suffering with an episode of facial paralysis caused by Bell's palsy? a. apply warm, moist heat to the affected side b. plan for frequent, small meals c. take like prescribed amoxicillin daily d. cover the eye on the affected side at night e. a soft diet will be helpful
a. apply warm, moist heat to the affected side b. plan for frequent, small meals d. cover the eye on the affected side at night e. a soft diet will be helpful
A client with severe mental illness believes a local minister stirred evil spirits into the community. When the client threatens to bomb the church, the client therapist notifies the minister and the police. What action was taken? a. demonstrated duty to warn b. followed the rogers legislation c. released information without proper authorization d. supported the client's recovery
a. demonstrated duty to warn
A nurse is caring for a client who smokes and has lung cancer. The client reports, "Im coughing because I have a cold that everyone has been getting" Which defense mechanism is he using? a. denial b. reaction formation c. suppression d. displacement
a. denial
A nurse is caring for a client with Parkinson's disease who is beginning to experience bradykinesia. Which action by the nurse is appropriate? a. give the client extra time to perform activities b. complete ROM exercises daily c. place the client on low protein, low calorie diet d. place suction equipment at bedside
a. give the client extra time to perform activities
The nurse is making a home visit with a client diagnosed with Alzheimer's disease and the clients partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain. The partner: a. has lost 15 lbs in last 2 months b. redirects the client when the client is frustrated c. placed locks at the top of the doors leading to the outside d. hired a housecleaner who comes every 2 weeks
a. has lost 15 lbs in last 2 months
SATA: A nurse is performing a mental status exam on a client who has new diagnosis of Alzheimer's disease? On which of the following components should the nurse be especially focused during the MSE? a. long term memory b. support systems c. presence pain d. affect e. grooming
a. long term memory d. affect e. grooming
A nurse is caring for a client who experiences a sudden episode of severe anxiety. Which medic action would be most appropriate to administer to the client? a. lorazepam b. buspirone c. sertraline d. paroxetine
a. lorazepam
A client sustains a L1-L2 vertebral fracture with partial spinal cord injury as a consequence of falling off a ladder. A nurse is developing a plan of care, recognizing that the priority should be which of the following? a. maintains spine immobilization b. preventin g autonomic dysreflexia c. preventing aspiration associated with placement of feeding tube d. administrating anticoagulant medication
a. maintains spine immobilization
A neonate has a collection of blood between the skull bone and its periosteum. To reassure the new parents who's infant has this condition, it is important to be aware of what: a. may occur with spontaneous vaginal birth b. happens only as the result of forceps or vacuum delivery c. is present immediately after birth d. will gradually absorb over the first few months of life
a. may occur with spontaneous vaginal birth
A nurse is caring for a client who is 40 weeks gestations and in labor. The client ultrasound examination indicates that the fetus is small for gestational age. Which fo the following intervention should be included in the newborn's plan of care? a. observe for meconium in respiratory secretions b. Monitor for hypoglycemia c. identify manifestations of anemia d. monitor for hypothermia
a. observe for meconium in respiratory secretions
A pregnancy women's amniotic membranes rupture. Prolapsed umbilical cord is suspected. what intervention would be the top priority? a. placing the woman in the knee-chest position b. preparing the woman for c-section c. starting O2 by face mask d. covering the cord in sterile gauze soaked in saline
a. placing the woman in the knee-chest position
A nurse is completing the admission assessment of client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? a. report of headache b. tachycardia c. absence of clonus d. polyuria
a. report of headache
A client with a diagnosis of severe anxiety appears agitate and has been pacing up and down the hall since admission. A nurse identifies which factors that will be important in order to track the extent of the clients condition? a. restlessness and impulse control b. obsessive thoughts and phobias c. hopelessness and helpness d. orientation, hygiene and grooming
a. restlessness and impulse control
A nurse is caring for a client with trigeminal neuralgia. Which client problem is the priority for the nurse? a. severe facial pain b. ptosis and diplopia c. unilateral facial numbness d. problems with communication
a. severe facial pain
A student nurse is sitting in the unit dining room talking to client after dinner. The client tells the student nurse, "My friend snuck a knife into the unit for me since im afraid of my roommate. I put it under my pillow. Don't tell anyone" Which action should the nurse take? a. tell the client the knife must be reported because it concerns the safety of the client and others b. keep the communication confidential but monitor the client closely c. keep the communication confidential but encourage the client to report the knife d. tell the client that all probability no further visitation by friends or family will be permitted
a. tell the client the knife must be reported because it concerns the safety of the client and others
A nurse is providing teaching about Kegel exercises to a group of clients who are in their third trimester of pregnancy. Which of the following statements by the client indicates understanding of the teaching? a. "These exercises help prevent constipation" b. "These exercises help pelvic muscles to stretch during labor" c. "They can help reduce back aches" d. "They can prevent further stretch marks"
b. "These exercises help pelvic muscles to stretch during labor"
After receiving change-of-shift report, which patient should the nurse assess first? a. 4 hour ago with spinal cord injury at L4-L5 whose deep tendon reflexes are +1 b. 2 hour ago with Gullian-Barre syndrome whose lower extremity paralysis has extended to the waist c. 1 hour ago with Parkinson's disease who reports feeling constipated and asks for a laxative d. 2 hours ago with myasthenia gravis who reports continuing points and diplopia
b. 2 hour ago with Gullian-Barre syndrome whose lower extremity paralysis has extended to the waist
A nurse is teaching a client who has a new prescription for baclofen, indicating that the drug will likely have which of following effects? a. Improve bladder emptying b. Ease muscle spasticity c. Decrease tremor d. Enhance muscle strength
b. Ease muscle spasticity
A nurse notes that a client with myasthenia gravis has an elevated temperature of 102.2 F, increased HR 120, and rise in BP 158/94, and is incontinent of urine and stool. What is the nurse's best action at this time? a. Recheck vital signs in one hour b. Notify the health care provider immediately c. Administer acetaminophen via rectal suppository d. Reschedule the client's physical therapy for tomorrow
b. Notify the health care provider immediately
A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? a. Continuous fetal monitoring b. ambulate twice daily c. obtain a daily weight d. assess deep tendon reflexes every hour
b. ambulate twice daily
A client fearfully runs from chair to chair crying "they're coming!" the client does not follow staff directions or respond to verbal intervention. The initial nursing action of highest priority of the following is a. encourage the client to clarify their feelings b. assess the clients situation for their safety c. take the client outside for a walk d. offer an outlet for the clients energy
b. assess the clients situation for their safety
As relates to fetal positioning during labor, nurses should be aware that: a. engagement is the term used to describe the beginning of labor b. birth is imminent when the presenting part is +4 to +5 cm below the spine c. the largest transverse diameter of the presenting part is suboccipitobregmatic diameter d. position is measure of the degree of descent of the presenting part of the fetus through the birth canal
b. birth is imminent when the presenting part is +4 to +5 cm below the spine
A nurse midwife is examine a client who is primigravida at 42 weeks gestation and states that she believes he is labor. Which of the following findings confirm to the nurse that the client is in labor? a. report of pain above the umbilicus b. cervical dilation c. brownish vaginal discharge d. amniotic fluid in the vaginal vault
b. cervical dilation
A RN is caring for a client with worsening anxiety being admitted to the inpatient psychiatric, unit on which 2 RNs, 2 LPNs and 2 mental health workers. which of the following activities are performed by the RN? a. showing the client the visitors area and showers b. completing the clients admission assessment c. taking the client's vitals d. administering acetaminophen for a headache
b. completing the clients admission assessment
A nurse is caring for a client with Parkinson;s disease and is taking levadopa-carbidopa. Which of the following therapeutic outcomes should be expected? a. improved bladder function b. decreased tremors c. delay in the disease progression d. relief of depression
b. decreased tremors
A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? a. maintain the client in the lithotomy position b. encourage the client to empty her bladder every 2 hours c. perform vaginal exam frequently d. remind the client to bear down with each contraction
b. encourage the client to empty her bladder every 2 hours
Which of the following medications would the nurse expect to provide teaching about while caring for a client with Parkinson's disease? a. levadopa/carbidopa and donepezil b. acyclovir and donepezil c. levodopa/carbidopa and selegeline d. pyridostigmine and baclofen
c. levodopa/carbidopa and selegeline
A nurse is caring for client who is facing major surgery to a remove a large tumor in the colon. During the working phase of the nurse-client relationship, a nursing action would be which of the following? a. review recent diagnostic test results in the medical record b. explore feelings about the diagnosis and upcoming surgery c. work to develop rapport with the client d. summarize what was discussed and what ramming to be talked about
b. explore feelings about the diagnosis and upcoming surgery
SATA: The following clients are evaluated in the ED. A nurse determines clients should be admitted to the inpatient unit. a. is discontinuing clonzepam following period of daily use b. has self-inflicted, multiple cuts on both arms and legs after hearing about death of friend c. new parent and hearing voices "smother your baby" d. was discovered walking around the neighborhood during a snowstorm wearing a bathing suit after separating from their spouse
b. has self-inflicted, multiple cuts on both arms and legs after hearing about death of friend c. new parent and hearing voices "smother your baby" d. was discovered walking around the neighborhood during a snowstorm wearing a bathing suit after separating from their spouse
A nurse in a provider's office is caring for a client who is 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? a. cocaine use b. hypertension c. blunt force trauma d. cigarette smoking
b. hypertension
A nurse is using the mental status exam while talking to a newly admitted client. Which component of MSE is priority for the nurse to assess? a. hygiene needs b. ideas of self-harm c. labile mood d. ability to speak coherently
b. ideas of self-harm
While providing care in an obstetric setting, the nurse should understand that after birth care of the woman with cardiac disease: a. is the same as that for any pregnant woman b. includes rest, stool, and monitoring of the effect of activity c. includes ambulating frequently, alternating with active ROM d. includes limiting visits with he infant to once per a day
b. includes rest, stool, and monitoring of the effect of activity
SATA: Which of the following medications should a nurse avoid administering to a client with myasthenia gravis? a. prednisone b. morphine c. lorazepam d. iron supplementation e. acetaminophen
b. morphine c. lorazepam
A nurse is caring for a client who is gravid 3, para 2, and is in active labor. The fetal head is at 3+ station after vaginal exam. Which of the following actions should the nurse take? a. apply final pressure b. observe for crowning c. observe for the presence of nuchal cord d. prepare to administer oxytocin
b. observe for crowning
SATA: A woman has been diagnosed with mild preeclampsia and will be treated at home. The nurse includes which of the following in her teaching plan? a. check respirations before and after taking oral magnesium sulfate b. place a dipstick into a clean-catch sample of her urine to test for protein c. reduce fluid intake to 40 oz of water each day d. do gentle exercise e. avoid excessively salty foods f. maintain strict bed rest in a quiet lit room with minimal stimuli
b. place a dipstick into a clean-catch sample of her urine to test for protein d. do gentle exercise f. maintain strict bed rest in a quiet lit room with minimal stimuli
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical finding should the nurse identity as an indication of toxicity of magnesium sulfate therapy and report to the provider? a. drowsiness b. respiratory distress c. nausea d. facial flushing
b. respiratory distress
A nurse expects that a client with generalized anxiety disorder will benefit most from regular use of which medication? a. benzodiazepine, such as buspirone b. selective serotonin reuptake inhibitor, such as sertraline c. selective serotonin reuptake inhibitor, such as clonazapam d. benzodiazepine, such as lorazepam
b. selective serotonin reuptake inhibitor, such as sertraline
In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to the possible side effects? a. urine output of 160 mL in 4 hours b. serum magnesium level 10mg/dL c. RR of 16 d. Deep tendon reflexes of 2+ and no clonus
b. serum magnesium level 10mg/dL
With regard to the assessment of female, male, and couple infertility, nurses should be aware that: a. semen analysis is for men, the postcoital test is for women b. the investigation takes 3 to 4 months and a significant financial investment c. the woman is assessed first, if she is not the problem the male partner is analyzed d. the couple's religious, cultural, and ethnic backgrounds provide emotional clutter that does not affect the clinical scientific diagnosis
b. the investigation takes 3 to 4 months and a significant financial investment
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. which of the following is the correct interpretation of the finding? a. the largest fetal diameter has passed through the pelvic outlet b. the lowermost portion of the fetus is at the level of the ischial spines c. the posterior fontanel is palpable d. the fetal head is in the left occiput posterior position
b. the lowermost portion of the fetus is at the level of the ischial spines
A nurse on the L and D unit is caring for a client following a vaginal exam by a provider which is documented as -1. Interpret the findings a. the presenting part is 1 cm below the ischial spines b. the presenting part is 1 cm above the ischial spines c. the cervix is 1 cm dilated d.the cervix is effaced 1 cm
b. the presenting part is 1 cm above the ischial spines
Which question as part of the health history will give the nurse assessing a client for Gullain-Barre syndrome the most information? a. "Did you get the flu vaccine yet?" b. "Have you taken a frug that suppresses the immune system?" c. "Have you experienced a respiratory virus in the past few weeks?" s. "Has anyone in your household had Gullain-Barre syndrome?"
c. "Have you experienced a respiratory virus in the past few weeks?"
A nurse is in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? a. "Its a minor inconvenience, which you should ignore" b. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone" c. "There is no way to predict how long it will last in each individual client" d. "It occurs during the first trimester and near the end of pregnancy"
c. "There is no way to predict how long it will last in each individual client"
A nurse is caring for a client who is at 37 weeks gestation and has placenta previa. The client asks the nurse why the provider does not an internal examination. Which of the following explanations of the primary reason should the nurse provide? a. "This could initiate preterm labor" b. "There is an increased risk of introducing infection" c. "This could result in profound bleeding" d. "There is an increased risk of rupture of membranes"
c. "This could result in profound bleeding"
Which if the following statements if made by nurse would be considered non-therapeutic communication? a. "it sounds as if you have had a difficult day" b. "you may be able to walk further if you use your oxygen tank while you walk" c. "Why do you continue to smoke when your spouse has lung cancer" d. "You look so tired today. Are you?"
c. "Why do you continue to smoke when your spouse has lung cancer"
A nurse is performing Leopold maneuvers on a client who is labor and determine the fetus is in RSA position. What should the nurse document as the presenting part? a. Shoulder b. Vertex c. Breech d. Mentum
c. Breech
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? a. limit alcohol consumption b. Increase intake of iron-rich foods c. Consume foods fortified with folic acid d. Avoid foods containing aspartame
c. Consume foods fortified with folic acid
Which action by the nurse is correct when palpation is used to asses the characteristics and pattern of uterine contractions? a. determine frequency by timing from the end of one contraction to the end of the next b. assess uterine contractions every 30 minutes throughout the first stage of labor c. evaluate the intensity by pressing the fingertips into the uterine fundus d. Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips
c. Evaluate the intensity by pressing the fingertips into the uterine fundus
A nurse in prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the correct due date? a. April 27, 2016 b. April 11, 2016 c. February 11, 2016 d. February 27, 2016
c. February 11, 2016
A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions would be best for the nurse to take? a. Keep TV on b. Hang paintings of people and animals on the walls c. Keep familiar personal items at the bedside d. Encourage bright lighting in the room at all times
c. Keep familiar personal items at the bedside
The nurse, caring for a patient whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence by: a. the patient needing to void b. uterine contractions occurring every 8-10 minutes c. a FHR of 180 with absence of variability d. Rupture of the patient amniotic membranes
c. a FHR of 180 with absence of variability
A nurse is admitting a client who is 33 weeks of gestation and has diagnosis of placenta previa. Which of the following is the priority nursing action? a. insert and IV b. monitor vaginal bleeding c. apply an external fetal monitor d. administer glucocorticoids
c. apply an external fetal monitor
A nurse is caring for a client who is 40 weeks gestation and in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the clients BP 82/52. Which of the following nursing interventions should the nurse perform? a. prepare for c-section b. assist the client to an upright position c. assist the client to turn onto her side d. prepare for immediate vaginal delivery
c. assist the client to turn onto her side
When lorazepam is prescribed on an PRN basis for a client who experiences episode of severe anxiety, a nurse includes in teaching the recommendation to do which fo the following? a. take medication daily b. report drowsiness c. avoid alcohol d. take the medication on an empty stomach
c. avoid alcohol
A client who sustained a recent cervical spine injury reports sudden feeling of flushed. When a nurse assess a BP of 180/110. The client is held to a sitting position. What should the nurse do next? a. do a rectal exam to check for fecal impaction b. administer the prescribed antihypertensive medication c. check the indwelling urinary catheter for kinks in the tubing d. turn on the fan to provide cooling
c. check the indwelling urinary catheter for kinks in the tubing
While providing care to a patient in active labor the nurse should instruct the woman that: a. the supine position commonly used in the US increased blood flow b. in sitting and squatting position abdominal muscle will work harder c. frequent changes in position will help relieve her fatigue and increase her comfort d. the "all fours" position on her hands and knees is hard on the back
c. frequent changes in position will help relieve her fatigue and increase her comfort
A nurse is providing teaching to a client and partner of an 85 yr. old with early stage Alzheimer's disease. Which partner statement indicates understanding of the drug donepezil that is prescribed for the client? a. increase my partner's appetite b. increased my partner's energy level c. help my partner's daily functioning d. help my partner sleep better
c. help my partner's daily functioning
A nurse is assessing a client in labor who has had an epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? a. vomiting b. tachycardia c. hypotension d. respiratory distress
c. hypotension
A nurse and health care provider are considering placing a client in restraints before using other methods of intervention violates the client's right to which of the following? a. refuse treatment b. informed consent c. least restrictive treatment d. confidentiality
c. least restrictive treatment
In relation to primary and secondary powers, the maternity nurse comprehends that: a. scarring of the cervix by previous infection or surgery may make the delivery a bit more painful but it should not slow or inhibit dilation b. pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push c. primary powers are responsible for effacement and dilation of the cervix d. effacement generally is well ahead of dilation in women giving birth for the first time, they are closer together in subsequent pregnancy
c. primary powers are responsible for effacement and dilation of the cervix
The nurse has received report regarding her patient in labor. The woman's last vaginal exam was recorded at 3 cm, 30%, and -2. The nurse's interpretation of the assessment is? a. the cervix is 3 cm dilated, 30% effaced, and presenting part is 2 cm below the ischial spine b. the cervix is effaced 3 cm, dilated 30%, and presenting part is 2 cm above the ischial spine c. the cervix is 3 cm dilated, 30% effaced, presenting part is 2 cm above the ischial spine d. the cervix is effaced 3 cm, 30% dilated, presenting part is 2 cm below the ischial spine
c. the cervix is 3 cm dilated, 30% effaced, presenting part is 2 cm above the ischial spine
Maternal phenylketonuria (PKU) is an important health concern during pregnancy because: a. women with PKU are usually retarded and should not reproduce b. a pregnant woman is more likely to die without dietary control c. the fetus may develop neurologic problem d. it is recognized cause of preterm labor
c. the fetus may develop neurologic problem
A nurse at prenatal clinic is caring for a client who is her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about upcoming changes in her life. Which is the following is an appropriate response by the nurse? a. "Perhaps you should see a counselor to discuss these feelings further" b. "Have you spoken to your mother about these feelings?" c. "Don't worry. You will be fine once the baby is born" d. "Ambivalent feelings are quite common for women early in pregnancy"
d. "Ambivalent feelings are quite common for women early in pregnancy"
A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? a. "Exercising during pregnancy is not recommended" b. "Daily jogging for up to 30 min is fine throughout pregnancy" c. Activities that raise body temperature, such as saunas and hot tubes, are safe until third trimester" d. "It is recommended that pregnancy clients limit their routine to stretching activities on a mat several times a week"
d. "It is recommended that pregnancy clients limit their routine to stretching activities on a mat several times a week" or b. "Daily jogging for up to 30 min is fine throughout pregnancy" ***WAS ACCEPTED***
A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following response should the nurse make? a. "All you need to do is relax" b. "Don't worry, I will be with you during the exam" c. "A pelvic exam is required if you want birth control pills" d. "What part of the exam makes you nervous?"
d. "What part of the exam makes you nervous?"
A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? a. "Everyone worries about her baby when she is in labor" b. "Your pregnancy is advanced so your baby should be fine" c. "We have a neonatal unit here thats equipped to handle emergencies" d. "You must be feeling scared and powerless"
d. "You must be feeling scared and powerless"
The care plan for a client includes increasing self-esteem via cognitive therapeutic approach. When the client tells the nurse, "Im stupid and will never get that job" what is the appropriate response? a. "it seems to me you are intelligent" b. "you should stop demeaning yourself" c. "it must be painful to feel that way' d. "lets talk about what you just said"
d. "lets talk about what you just said"
A nurse is caring for a client who is in preterm labor with a current L/S ration of 1:1. Which of the following actions should the nurse take? a. Infuse a bolus of IV fluid b. Administer hydralazine 25 mg IV c. Prepare the client for immediate delivery d. Administer betamethasone 12 mg IM
d. Administer betamethasone 12 mg IM
Which lab result will a nurse expect in a client experiencing difficulty sleeping due to an irresistible urge to move the legs while lying in bed at night? a. Vitamin B12 150ng/mL (Norm: 200-900) b. Hct 58% c. Platelets 250 d. Ferritin 5 ng/mL (Norm: 12-300)
d. Ferritin 5 ng/mL (Norm: 12-300)
A nurse assess a client who commonly experiences anxiety. Which comment by the client indicates a likely diagnosis of OCD? a. I often cannot sleep because I am worrying about what will happen tomorrow b. I do not go out of my house for fear of having a panic attack and being alone c. I am afraid to travel by airplane or train d. I check where my car keys are about 10 time before I got to bed
d. I check where my car keys are about 10 time before I got to bed
A nurse is preparing to administer magnesium sulfate IV to client who is experiencing preterm labor. Which of the following is the priority nursing assessment? a. Temperature b. FHR c. Bowel sounds d. RR
d. RR
A nurse is caring for a client with Alzheimer's disease who is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who than becomes upset and frightened. Which of the following actions should the nurse take? a. place the client in restraints b. reorient the client to time and place c. move the client to a room at end of hall d. assist the client to the correct room
d. assist the client to the correct room
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to provider? a. contractions occurring every 3-5 minutes b. client reports feelings contractions in lower back c. contractions are strong in intensity d. contractions lasting longer than 90 sec
d. contractions lasting longer than 90 sec
A nurse plans to administer pyridostigmine to a client with myasthenia gravis at which time? a. following th enid-day meal b. in the evening before bed c. as needed after strenuous activity d. in the morning before breakfast
d. in the morning before breakfast
A nurse is assisting with systemic desensitization or a client who has an extreme fear of elevators. Which of the following actions should the nurse implement? a. demonstrate riding in an elevator and then ask the client to imitate the behavior b. first stand with the client in front of the doors and use the relaxation technique c. stay with the client in an elevator until anxiety subsides d. instruct the client to get on an elevator, use relaxation technique and ride to 5th floor
d. instruct the client to get on an elevator, use relaxation technique and ride to 5th floor
A nurse is admitting a client who is 30 weeks gestation and is preterm labor. The client has new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which fo the following explanation? a. increased FHR b. it is used to stop preterm labor contractions c. it halts cervical dilation d. it promotes fetal lung maturity
d. it promotes fetal lung maturity
For women addicted to opioids, the nurse expects which treatment to be prescribed during pregnancy? a. detoxification b. smoking cessation c. 4 P's Plus d. methadone maintenance
d. methadone maintenance
During assessment, anise observes that client is laughing. The client states, "How should the nurse document the client mood and affect?" a. affect is sad and mood is flat b. affect is labile and mood is euphoric c. affect is flat and mood is sad d. mood and affect are incongruent
d. mood and affect are incongruent
To endure that newly admitted client who feels compelled to wash their hands multiple times daily is on time for lab tests, nurse should take which action? a. remind the client several times of upcoming appointment b. limit number of times the client washes hands c. tell the client that is their responsibility to be on time for appointment d. proved ample time for the client to complete rituals
d. proved ample time for the client to complete rituals
During a conversation with a nurse, a client jumps rapidly from one topic to another and sometimes seems confused. To what aspect of the mental status exam does this behavior relate? a. Though content b. judgment c. affect d. thought process
d. thought process
When the client struggling with generalized anxiety disorder would charger nurse assign to a new nurse beginning practice in an outpatient treatment program. a. tells the charge nurse they would prefer to be dead b. is pacing wildly around the unit and yelling at staff to leave them alone c. was just admitted to the program for the first time and is refusing meds d. was admitted to the program 3 days ago and is attending group activities
d. was admitted to the program 3 days ago and is attending group activities
