Final

A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?

Dark, scanty urine.

A multigravida client that is diagnosed with chronic hypertension is now in preterm labor at 34 weeks gestation. The primary health care provider has prescribed magnesium sulfate at 3g/hr. Which assessment finding indicates that the intended therapeutic effect has occurred?

Decrease in the frequency and number of contractions

A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply.

Do not allow blood pressures or blood draws in the affected arm. use an electric razor for shaving. elevate the left arm, perform hand pump exercises.

What is done to decrease tumor size in superior vena cava syndrome?

High dose radiation therapy (also steroid & diuretics)

A patient with cerebral palsy has slow, worm-like writhing movement. What causes this?

Athetosis (spasticity)

The nurse should closely monitor the client with an open fracture for which complication?

Osteomyelitis (& hemorrhage)

A client has the leg immobilized in a long leg cast. Which finding indicates the beginning of circulatory impairment?

Tingling of toes

Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the:

blood pressure

The nurse is preparing to administer a vitamin K injection to a neonate shortly after birth. What statement by the mother indicates that she understands the purpose of the injection?

"My baby does not have the normal bacteria in his intestines to produce this vitamin, therefore he's at risk for bleeding."

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). Which information is most important for the nurse to share?

"The risk of pelvic inflammatory disease will be higher with the IUD."

The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?

A woman at 32 weeks gestation and is pre-eclamptic with +3 proteinuria

A client is admitted with suspected abruptio placentae. The nurse should assess the client for which of the following signs and symptoms? Select all that apply

A. Bleeding that is concealed or apparent B. Abdominal rigidity C. Painful abdomen

Blood pressures or blood draws in the affected arm, sun exposure, trauma with a sharp razor, and immobilization increase the risk of lymphedema. Elevation of the arm and hand pump exercises promote lymph flow and reduce edema. The nurse is teaching a client about prostate cancer. Which points should be included in the instruction? SATA

A. Prostate cancer is usually multifocal and slow-growing. B. Most prostate cancers are adenocarcinoma. C. The incidence of prostate cancer is higher in men of African descent, and the onset is earlier.

A female client is treated for trichomoniasis with metronidazole. What should the nurse tell the client about this medication?

A. The medication will make the urine a darker color. B. She should continue her oral contraceptive use during this treatment. C. She should avoid alcohol during treatment and for 24 hours after completion. D. Her partner will need to be treated too.

What should be done prior to administration of Medroxyprogesterone birth control injection for a patient that is 6 weeks postpartum?

A. Verify that the patient is not pregnant B. Verify that the patient is not breastfeeding C. Ask if she is currently experiencing postpartum depression.

The nurse is developing a program about skin cancer prevention for a community group. Which information should be included? SATA

A.Purchase sunscreen containing benzophenones to block UVA and UVB rays. B. Use sunscreen with a minimum of 30 sun protection factor (SPF.)

The client has just given birth to a healthy, full-term infant. The client is Rho(D) negative and her baby is Rho(D) positive. Which intervention will take place to reduce the possibility of isoimmunization?

Administering Rho(D) immune globulin to the mother, IM, within 72 hours

Medications used to manage postpartum hemorrhage include

Pitocin, methergine, hemabate, cytotec

Which action should the nurse include in the care plan for a child with leukemia who has an ANC of 400

Restrict staff and visitors with active infections

Priority after birth

airway

Mastectomy postop teaching to prevent lymphedema and increase circulation. SATA

A. Avoid heavy lifting >10lbs B. Compression sleeve C. Elevate extremities D. ROM asap.

The nurse is developing a plan of care with a client who has leukemia. What instructions should the nurse include in the plan? SATA

A. Monitor temperature and report elevations B. Recognize signs and symptoms of infection C. Avoid crowds D. Maintain the integrity of skin and mucous membranes

Which information would be important to include in the teaching plan for the client who wants more information on ovulation and fertility management?

A. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. B. Take folic acid with vitamin C or orange juice

Three hours ago, an adult was thrown from a car into a ditch. The client is now in the emergency department in stable condition. Vital signs are within normal limits. The client has an open fracture of the right tibia. For which sign should the nurse be on alert for?

Infection

Tricyclic Antidepressants. What's the Mechanism of Action?

Inhibits the reuptake of norepinephrine and serotonin from the synaptic cleft.

How can the nurse ease a baby's during circumcision?

sucrose, non-nutritive sucking

A patient having an anaphylactic reaction has been given epi and O2 was started. What other medication will be given? SATA

1. Antihistamines (diphenhydramine/1st gen = Benadryl = drowsy, 2nd gen ranitidine = less drowsy 2. Corticosteroids methylprednisolone 3. Bronchodilator- albuterol IV fluid

Which patient should the pediatrician attending stay with during birth?

37 weeks gestation with group B strep. IV penicillin is given

A male client reports having impotence. The nurse should teach the client that which medication is a contributing factor to impotence?

Antihypertensives

What is a risk factor for cervical cancer?

Adolescent pregnancy

The nurse should teach the client with erectile dysfunction (ED) to alter his lifestyle by doing which?

Avoiding alcohol

A college student asks the nurse about the student's grandfather, who just received a diagnosis of Huntington's disease. The student wants to know if the student will have the disease too. What should the nurse tell the student?

B. "Huntington's disease is an autosomal dominant disease. C. "Huntington's disease doesn't skip a generation." D. "Huntington's disease effects both genders equally." E. "There's a 50% chance you'll have the disease."

What is the gold standard for the diagnosis of Non-Hodgkin's lymphoma?

Biopsy - This is the definitive diagnosis and types protein markers.

The nurse is caring of a patient with a spinal cord injury. The extent of the client's injury is shown below. Which finding is expected when assessing this client?

Dysfunction of bowel and bladder

When treating a patient with compartment syndrome, what measures should the nurse consider to be contraindicated? Select all that apply.

Elevation of the limb above heart level. Application of cold compresses.

The nurse in the labor and delivery unit is caring for a 25-year-old gravida 3, para 2 patient in active labor. The nurse has identified late fetal heart decelerations and decreased variability in the fetal heart rate and notified the health care provider (HCP) on call, who thinks that the pattern is acceptable. What would be the priority action at this time?

Go up the chain of command and communicate the assessment of the fetal heart rate findings clearly to the next appropriate HCP

Which instruction(s) should the nurse give to a female client who just received a prescription for oral metronidazole (Flagyl) for treatment of trichomonas vaginalis? (Select all that apply.)

Increase fluid intake, especially cranberry juice. Avoid drinking alcohol while taking this medication. Use condoms until treatment is completed. Ensure that all sexual partners are treated at the same time.

How would a multiple myeloma tumor causing spinal cord compression be treated to decrease the tumor size?

Radiation then surgery to debulk if radiation is unsuccessful.

A multigravid client at 34 weeks' gestation with premature rupture of membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vitals are as follows: bp 120/80, temp 100, HR 100, RR 18. Which medication would the nurse expect the primary health care provider to prescribe?

Intravenous penicillin

A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the priority nursing action in the immediate postoperative period?

Keep a surgical tourniquet at the bedside

The nurse is teaching a client with Crohn's disease about a low residual diet. Which selection by the client would show that the teaching has been effective?

Lean beef, white rice, tea

A school-aged child with attention deficit hyperactivity disorder is prescribed methylphenidate. What finding should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug?

Loss of appetite

A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. Which problem is the nurse most likely to find during the infant's assessment?

Low birth weight

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be a clean from the right arm, and the clients left arm and hand should be elevated as much as possible to prevent

Lymphedema

At 24 hours after delivery, the patient has hypotension, itching, nausea, and vomiting, and the newborn has developed respiratory depression. On reviewing the patient's medical history, the nurse finds that the patient was given meperidine (Demerol) 1 hour before the delivery. Which medication does the nurse expect to be prescribed for the newborn and the patient after the delivery?

Naloxone (Narcan)

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

Oxytocin

Tanya, a 30-year-old woman, is being prepared for a planned cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanya's blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurse's best response is to

Place Tanya in a left lateral tilt

A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their HCP because the mother should be evaluated further for which complication?

Postpartum depression

An adolescent tells the nurse that she would like to use tampons during her period. What should the nurse do first?

Provide information about preventing toxic shock syndrome.

While caring for a neonate of a woman with diabetes soon after birth, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonates blood glucose level and it is 60 mg/dL (3.3 mmol/L), but the neonate continues to exhibit jitteriness and tremors. The nurse should first:

Re-feed the infant to continue to increase the blood glucose level and wrap them in blanket

A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:

Reposition the client, apply oxygen, and increase IV fluids

A client delivered a healthy full-term baby girl 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action?

Tachycardia and hypotension (shock!)

The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control?

Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain

A grandson who calls the crisis center expressing concern about his grandmother who lost her husband a month ago states, "She has been in bed for a week and is not eating or showering. She told me that she did not want to kill herself, but it's not like her to do nothing for herself. She won't even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which of the following reasons?

The behaviors may reflect passive suicidal thoughts.

Which statement by the client indicates an understanding of the teaching regarding the use of corticosteroids during preterm labor?

The corticosteroids may help my baby's lungs develop.

A nurse discusses with parents the procedures that will be performed on their neonate immediately after birth. The nurse determines that the instructions have been understood when the parent states that which procedure will be done to the neonate first?

The neonate will be dried and stimulated to cry. 1st. The neonate will be suctioned.

The parents of a 12-year-old girl ask why their daughter, who is not sexually active, should receive the HPV vaccine. What should the nurse tell the parents?

The vaccine is most effective against cervical cancer if given before becoming sexually active. Side effect is hypotension and syncope. Have the patient wait for 30 minutes before leaving after injection.

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse?

This antibiotic helps keep babies from contracting eye infections.

Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1.5 minutes. The uterine resting tone is greater than 20 mm mercury with an abnormal fetal heart rate and pattern. Which of the following actions should the nurse take?

Turn off the oxytocin infusion

After administration of an epidural block for labor analgesia, the client's blood pressure decreases from 130/75 to 90/50. What intervention should the nurse initiate next?

Turn the client to a left lateral position

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?

an increase in the pulse from 88 to 102 BPM

What woman is at greatest risk for early postpartum hemorrhage?

a woman with severe preeclampsia on magnesium sulfate whose labor is being induced.

Risk factors for pre-rupture of membranes

alcohol, smoking (can cause the baby to be born with immature lungs)

A patient has been placed on long-term sulfasalazine therapy for the treatment of ulcerative colitis. The nurse should encourage the patient to eat which foods to help avoid the nutrient deficiencies that may develop as a result of this medication?

green, leafy vegetables (folic acid source)

Which diet would be MOST appropriate for the patient with ulcerative colitis?

high-protein, low-residue

The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient. closely for which of the following abnormalities associated with this oncologic emergency?

hypocalcemia

An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods and liquids through a syringe. The nurse determines his biggest nutritional risk factor is:

impaired oral motor control.

Manic patient saying inappropriate things - have him do activities to help in the common room. Anxious vital signs and UAP?

report to the nurse.

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem?

respiratory distress syndrome

Femor fracture in cast

risk for fat embolism and compartment syndrome. Don't scratch with a hanger. No lotion or powder.

A patient with TB is taking isoniazid (INH). What should the nurse instruct the patient to do to help prevent the development of peripheral neuropathies?

supplement the diet with pyridoxine (vitamin B6)

The nurse is caring for a multigravida woman who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment?

temperature of 100.8 F

Factors affecting fertility

tight underwear, lubrication, hot tub use, biking, long-distance running, irregular cycles.

Mom with increased temp

uterine infection, late sign of hemorrhage

Which common characteristics should the nurse include in the teaching plan for a multiparous client after giving birth to a neonate diagnosed with Down's syndrome? SATA

webbed neck, congenital heart defects, epicanthal folds, hypotonia

A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate?

Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure

A nurse is planning care with a family of a four-year-old in preschool who is often disruptive in class, is difficult to engage, and rarely speaks. The child flaps his arms and screeches when he is upset. What would be the most appropriate responses for the nurse to make? SATA

B. Has your child been evaluated by a pediatrician? He seems to have some behaviors that are abnormal for a child of his age C. How does your child behave at home? If you do not see him acting out behavior at home, part of his problem may be dealing with new situations such as school. D. How do you respond if he disobeys or acts out at home? If your techniques help, stop, or prevent negative behavior, perhaps the teachers can try similar measures at school

What medication education is necessary for someone taking a tricyclic antidepressant?

Can take 6-8 weeks to see therapeutic effects. The HCP will monitor and gradually decrease the dose if the medication is discontinued. Do not stop taking abruptly. Can cause suicidal ideation and worsen depression Side effects include sedation, seizures, and tachycardia

A patient would need further education about Non Hodgkin's lymphoma by which statement?

Reed Sternberg cells are present

Assessment of a primigravida in active labor reveals cervical dilation at 9 cm with complete effacement and the fetus at +1 station. What should the nurse do when the primary care provider prescribes meperidine 50 mg intramuscular (IM) for the client?

Refuse to administer the medication to the client.

A 16 year old primigravida client admitted at 38 weeks gestation with severe preeclampsia is given intravenous magnesium sulfate and lactated ringer's solution. The nurse should obtain which of the following information?

Respiratory rate every hour

A client diagnosed with cancer is receiving chemotherapy. The nurses should assess which diagnostic value while the client is receiving chemotherapy?

bone marrow cells

A client has a staging procedure for cancer of the breast and asks the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer?

inflammation with peau d'orange.

A child who is of preschool age is diagnosed as having severe autism. The most effective therapy involves which intervention?

one one one play therapy