Lifespan Review (previous quizzes)
Possible nursing diagnosis for postpartum woman
- rx of bleeding r/t uterine atony, retained placenta, and urinary retention - rx for impaired urinary elimination/retention -alteration in comfort - rx for infection - rx for ineffective breastfeeding - rx for constipation - rx for disturbed sleep - altered skin integrity
A 26-year-old preschool teacher is seen for an annual physical and a birth control planning visit as she is planning to be married in 6 months. She returns for results and is devastated to learn she has gonorrhea. What might contribute to her being unaware of her sexually transmitted infection? a. She has been asymptomatic b. She is in a monogamous relationship c. She is uncomfortable examining her genitals d. She is not familiar with the symptoms of gonorrhea
a
A 56-year-old male comes to the clinic complaining of erectile dysfunction. What focused assessment would be essential prior to possibly receiving a prescription for a phosphdiesterase inhibitor (PDE-5)? a. cardiovascular b. musculoskeletal c. respiratory system d. neurocognitive
a
A child is being discharged following hospitalization for asthma exacerbation. When providing teaching for this non-English speaking family, what is the most important to consider? a. Address any cultural healing beliefs the family may have. b. Provide illustrated, written discharge instructions in their native language. c. Ensure the family understands the order in which to use the medications properly. d. Have the family verbalize how to use the asthma equipment.
a
A client at 32 weeks is complaining of pregnancy related back pain. Which of the following would be helpful? a. Performing pelvic tilt exercises to strengthen back muscles and relieve pain b. Always wearing a support belt or girdle around the abdomen to support the back muscles c. Spending more time lying supine and elevating the feet daily d. Taking ibuprofen daily as needed to treat the pain
a
A client had a positive home pregnancy test five days ago. She is in the office complaining of severe abdominal pain. What does the nurse suspect? a. ectopic pregnancy b. trophoblastic disease c. pelvic inflammatory disease d. molar pregnancy e. hydatitidiform mole
a
A client is on day one of withdrawing from alcohol, which symptom is most concerning? a. Blood pressure of 180/100 b. Tactile hallucinations c. Mood rating of 2/10 d. Headache and nausea
a
A client presents to the department believing she might be in labor. What indicates true labor? a. cervical dilation and effacement are occuring b. fetal descent into the pelvic inlet is apparent c. contractions occur every 3 to 5 minutes d. the bag of waters has ruptured
a
A laboring client is complaining of severe back pain at 8 cm dilated and 100 percent effaced. The nurse explains the client's severe back pain is most likely caused by the fetus being in what position? a. occiput posterior (OP) b. occiput anterior (OA) c. breech position d. transverse lie
a
A laboring client is receiving oxytocin augmentation for her labor. Contractions are occurring 3 minutes apart and her most recent contraction lasted 110 seconds. What is the priority nursing action? a. Stop the pitocin b. Notify the charge nurse c. Provide emotional support d. Contact the anesthesiologist for an epidural
a
A laboring client requires an emergency cesarean section due to fetal distress. Who is responsible to obtain informed consent? a. The care provider who will be performing the caesarean section b. The charge nurse of the labor and delivery unit c. The care manager assigned to labor and delivery d. The nurse who will be circulating in the operating room
a
A male patient grimaces and cries out whenever he positions himself in bed or moves from the bed to the chair in his room. The patient repeatedly tells the nurse he is not in pain. The nurse's response is to: a. Provide patient teaching about pain control and effects on healing b. Accept the patient's report of pain and advocating for him to not take pain medication c. Obtain an order to medicate the patient against his will d. Confront the patient and demand more information
a
A new mother is breastfeeding and the nurse notes the infant has only a small amount of the areola in the mouth. The nurse instructs the mother to place a finger in the infant's mouth and detach the infant. Why did the nurse stop the mother from nursing? a. The small amount of areola will cause increased soreness for the mother b. The position of the infant at the breast was wrong c. The mother was not breastfeeding properly d. The infant was not getting enough breastmilk
a
A nurse prepares to present information at a nursing conference on how to promoting cognitive function in older adults. Which of the following is most important to include in the presentation? a. Determine the client's need for eyeglasses, magnifying glasses, and hearing aids b. Plan longer sessions to teach the information due to cognitive decline c. Review all medications for potential interactions d. Assist the client to develop realistic expectations of the aging process
a
A patient received a nebulized dose of Albuterol for his asthma. What side effect will you monitor for? a. tachycardia b. cold intolerance c. bradycardia d. drowsiness
a
A patient reports having used corticosteroids frequently due to repeated respiratory infections. She cites a history of fractures dating back 3 years. What diagnostic test would be useful in determining if she has osteoporosis? a. A dual energy X-ray absorptiometry test (DEXA scan) b. Chorionic Villi Sampling c. Ultrasound d. Amniocentesis
a
A patient was admitted to the emergency department with asthma exacerbation. Which medication side effect would the nurse assess for in this patient? a. tachycardia b. drowsiness c. nasal flaring d. bradycardia
a
A patient with COPD would be prescribed which diet in order to reduce the risk of developing respiratory failure? a. a low carbohydrate diet b. a low salt diet c. a regular diet d. a mechanical soft diet
a
A patient/client was admitted due to overwhelming stress and inability to manage activities of daily living. Which example of therapeutic communication would be effective in the planning phase of the nursing process? a. "We have discussed coping skills you have used previously. Let's see how these coping skills could be effective in your current situation." b. "I notice you seem to be responding to voices I do not hear." c. "Tell me in your own words what brought you to the hospital." d. "I hope you learned something in your therapy session which will be useful to you
a
A pregnant client presents to the clinic who has a hearing deficit. What is most important to remember when giving this client instructions? a. Allow time for the client to process information and respond; validate the client understands the information provided b. Provide ear care to remove excess ear wax, reposition hearing aids, and then begin the instructions c. No special accommodations are needed as she is young enough to compensate appropriately for hearing loss d. Select a quiet environment where teaching can occur without background noise
a
All people with teeth should use a fluoridated toothpaste. What instructions would be given? a. Use a pea sized amount of toothpaste, spit, and wait 30 minutes before eating. b. Use a pea sized amount of toothpaste, swallow when finished, and do not eat for 30 minutes. c. Cover the surface of the toothbrush with toothpaste, swish and spit when finished. d. Cover the surface of the toothbrush with toothpaste and brush thoroughly for 3-5 minutes.
a
An 18 month old likes to suck a bottle at nap and bed time. What fluid would reduce the risk of dental decay? a. Water b. Formula c. Milk diluted with water d. Juice diluted with water
a
An 85-year-old male patient has bedridden for two weeks. Which of the following complaints by the patient indicates the patient is developing a complication of immobility? a. Stiffness of the right ankle joint b. Constipation c. Short term memory loss d. Decreased appetite
a
An abused woman presents in the emergency department for treatment. What is the nurse's priority at this time? a. Ensure privacy and a sense of security for the victim. b. Establish rapport during the assessment with the victim and the abuser. c. Notify protective services immediately. d. Request a security guard to be present outside the patient curtain.
a
During a prenatal assessment, the nurse wants to collect information about possible abuse, which of the following initial questions would be most appropriate? a. "What happens when you and your partner argue?" b. "Is there something that is bothering you?" c. "Are you ever frightened of your partner?" d. "Do you ever feel threatened or bullied by your partner? "
a
Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate? a. Give the client a paper bag and have her breathe into it. b. Encourage the client to inhale deeply and then hold her breath for ten seconds c. Apply a nasal cannula at 3 liters. d. Tell the client to breathe quickly. and then hold her breath.
a
Most gastroenteritis: a. is of viral origin and spread via the fecal-oral route via poor handwashing b. results in increased intracranial pressure and bulging anterior fontanel in infants less than 18 months of age c. results in fluid volume overload and the need for diuresis d. is usually caused by helicobacter pylori and treated with proton pump inhbitors
a
Oral contraceptive pills and the vaginal ring both require which of the following to be effective? a. To be used for three weeks and then stopped for one week for normal menstrual cycle can occur b. When used as directed, both are nearly 100% effective in preventing pregnancy. c. Both methods will have hormonal side effects d. To always be used with a condom to prevent all sexually transmitted infections
a
Patient centered care means: a. working with the individual to increase patient engagement in shared decision making, trust, and treating each respectfully as a unique individual b. using the nursing process consistently with every patient and consistently reaching outcome goals c. treating everyone exactly the same in every way every day d. working with the interdisciplinary team to meet all the patient's needs and concerns - mentally, physically, emotionally, and economically
a
Pediatric patients will have a respiratory rate that is a. less than an infant and greater than an adult b. greater than an infant and less than an adult c. greater than an infant and greater than an adult d. less than an infant and less than an adult
a
Physical activity and exercise improve the functioning of many body systems. Exercise improves what normal body function of the gastrointestinal system? a. Peristalsis b. Use of fatty acids c. Metabolic rate d. Insulin responsiveness
a
Pregnancy induced hypertension is characterized by: a. Occuring after 20 weeks and blood pressure is elevated on two separate occasions b. Occurs between 12 and 20 weeks gestation and blood pressure is elevated on two or more occasions c. Occurring prior to conception but worsens with pregnancy d. Hypertension that is being treated prior to pregnancy but changes to pre-eclampsia during pregnancy
a
Small white marks on visible on a newborn's nose. What are these small white marks called? a. Milia b. Erythema toxicum c. Mongolian spots d. Port wine stain
a
Spirituality and religion: a. are part of comprehensive individualized plans of care b. are very private and do not influence medical care c. may be uncomfortable for people to discuss, but they have to do it anyway d. must be understood in order to provide medical care
a
The nurse assesses the effectiveness of a breastfeeding session using which assessment tool? a. LATCH score b. APGAR score c. Denver Developmental Standardized Test d. Braden score
a
The nurse is caring for a terminally ill pediatric client. The parents have decided to remove their child from life support. Which action by the nurse displays the role of client advocate? a. Respecting the parents' decision b. Referring the parents to social services c. Telling the parents they are making the right decision d. Asking to be assigned to a different client
a
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to a, Exercise doing weight bearing activities b. Exercise to reduce weight c. Avoid all exercise activities that increase the risk of fracture d. Exercise to strengthen muscles and thereby protect bones
a
The patient asks, "Why do I feel so bloated before my menstrual period begins? I am constipated, my breasts are tender, and I'm always hungry." How would the nurse best respond? a. "Progesterone can cause increased appetite, breast tenderness, bloating, increased body temperature, and constipation." b. "These symptoms could be caused by any of the hormones like testosterone, estrogen, progesterone, and follicle stimulating hormone." c. "Estrogen can cause bloating and water retention which are quite common pre-menstrual complaints." d. "This is just how the body prepares for pregnancy."
a
The primary care provider is concerned the patient may have a hiatal hernia or peptic ulcer or gastroesophageal reflux disease. What diagnostic test would be best to determine what the upper gastrointestinal issue is? a. esophagogastroduodenoscopy (EGD) b. colostomy c. gastric bypass surgery d. barium swallow followed by a barium enema
a
What causes the nurse to suspect failure to thrive in a six month old infant? a. The height is in the 75th percentile and the weight is in the 15th percentile for age b. The infant cries when his father approaches the crib c. The infant has only 6-8 wet diapers per day d. The chest is bigger than the head
a
What is the purpose in giving a patient feedback? a. To give the client critical or necessary information b. To evaluate the client's behaviors and ensure he understands them fully c. To advise the client on expected behaviors and attitudes d. To give the client advice which may be useful to him
a
When discussing a menstrual cycle, day 1 is defined as: a. The first day of the menstrual period b. The day the woman stops menstruating c. The day the woman ovulates d. The day the woman starts her period for the very first time
a
When obtaining a menstrual history, what would be important information to obtain? a. Age at menarche, average duration of menstrual cycle, date of last menstrual period, and any concerns or changes with menstrual cycle b. Assess general health, and ask questions about pregnancy history and menses c. Assess general knowledge of the physiology of menstruation, self-care, and personal hygiene d. Onset of sexual activity, number of sexual partners, type of birth control, concerns about menstrual cycle
a
Which Erikson's stage of development is most unstable and challenging in terms of developing a personal identity? a. Adolescence b. Middle Adulthood c. Pre-school d. Toddler
a
Which client needs a biophysical profile? a. Client at 34 weeks who had a non-reactive nonstress test b. Client at 28 weeks who still feels nauseous c. Client whose fasting blood sugar is 96 and postprandial glucose is 119 d. Client at 12 weeks who reports she hasn't felt the baby move
a
Which infant is at the highest risk of infection following discharge? a. Newborn with a freshly circumcised penis b. Newborn with multiple heel sticks from glucose checks c. Newborn with milia d. Newborn with erythema toxicum
a
Which pregnant patient would you assess first? a. A client who has hyperemesis gravidarum who has lost 13 pounds since her last prenatal visit b. A 6 week pregnant woman who is having a painless dark brown vaginal discharge c. A 12 week pregnant woman who has not yet felt her baby move d. A new client who is refusing to sign a consent for blood transfusion following delivery (if needed) due to religious convictions e. A 14 week pregnant woman who does not have protein in her urine
a
Which statement by the nurse would be considered therapeutic if a patient were actively working to explore and solve a personal problem/issue? a. "You seem to be motivated. I can see you are thinking about and working hard on this." b. "You could probably make a list of all the behaviors you want to change." c. "Do you really think your life will be better when you work out a solution?" d. "Why do you think your life will be better if you make changes?" e. "You probably should limit your thinking to just one problem at a time."
a
Which statement is most accurate regarding care of the umbilical cord? a. Allow the cord to dry naturally and fall off on its' own. b. Apply alcohol to the cord six times daily until it falls off. c. Apply hydrogen peroxide to the cord three times daily. d. Never examine or touch the cord as it may lead to sepsis.
a
Why is it important to test for helicobacter pylori (h. pylori)? a. An untreated infection may lead to ulcerations b. Helicobacter pylori causes bad breath which may impair intimate relationships c. A lack of healthy flora such as helicobacter pylori can cause dyspepsia d. Helicobacter pylori can be easily treated with medication
a
SA*** Which birth control methods require a prescription? Select all that apply. a. Contraceptive hormonal patch b. Oral contraceptive pills c. Contraceptive hormonal patch d. Spermicides e. Condoms
a,b,c
Which statements indicate the the first trimester pregnant patient understands the teaching related to a transvaginal ultrasound? Select all that apply. a. "I may feel slight pressure when the lubricated probe is inserted in my vagina." b. "I may feel some slight movement of the probe during the examination." c. "My baby will have a heartbeat on ultrasound." d. "I will be able to find out if my baby has any abnormalities in growth and development." e. "I will need to have this test repeated every 4 weeks until the baby comes."
a,b,c
SA*** Which information would be included in the asthma teaching plan at discharge to prevent recurrence of asthmatic episodes? Select all that apply. a. Avoiding triggers or minimizing exposure as much as possible b. Obtaining an annual flu vaccine c Using a peak flow meter daily d. Carrying a rapid acting bronchodilator inhaler e. Using an inhaled corticosteroid when feeling short of breath
a,b,c,d
SA*** Which of the following statements about alcohol use would be concerning? Select all that apply. a. "I drank heavily before I even realized I was pregnant, so there is no benefit in stopping now." b. "It doesn't matter that much if I drink in the third trimester as the baby will be fully developed by then." c. "When I drink during my pregnancy, it will make my baby have to go through withdrawal but then he or she should be fine." d. "I plan to stop drinking as soon as I start thinking about trying to have a baby." e. "As long as I don't binge drink, I can safely drink alcohol during pregnancy."
a,b,c,e
Foods that may cause constipation include: a. Rice, bread, potatoes, pasta b. Pastries, candies, and products with a lot of sugar or sucrose c. Cooked vegetables and fruits d. Meats such as veal, poultry, fish and beef e. Raw fruits and vegetables
a,c,d
SA*** What are some of the causes of gastroesophageal reflux disease (GERD)? Select all that apply. a. Stomach cancer b. Obesity or significantly overweight c. An incompetent lower esophageal sphincter d. Dietary choices e. Hypertension f. Stomach acid refluxing up into the esophagus
all but a and e
SA*** What information should be documented during the admission process to the newborn nursery following delivery. Select all that apply. a. Gestational age based on due date b. Apgar score at one and five minutes of age c. Time of birth d. Family presence at birth e. Any stool or urine passed since birth f. Type of delivery (vaginal or C-section) g. City and state of birth h. Birth weight
all but d and g
SA** Which of the following areas are included in a Holistic Health Assessment? a. Spiritual assessment: Respectfully ask about religious and spiritual practices and determine if nursing care will need to be altered. b. Physiological assessment: Complete a physical assessment. c. Developmental assessment: Consider how psychosocial and cognitive development may affect the patient's response to the health issue. d. Cultural assessment: Discuss special diet, values or culture-specific requests. e. Psychological assessment: Review potential stressors that might exacerbate the ailment. f. Sociological assessment: Discuss family networks and who can help at home
all of them
SA*** Which of the following symptoms are associated with polycystic ovarian syndrome? Select all that apply. (Per NCLEX: answer may be one or more or all of the answer options.) a. Elevated levels of testosterone b. Hirsuitism c. Painful periods and pain between periods d. Ovulatory and menstrual dysfunction e. Multiple ovarian cysts.
all of them
SA*** Which of the following would be important to include in patient teaching? a. Include family members in the patient teaching (if the patient agrees) b. Determine the patient's learning style and adjust presentation as needed c. Stimulate the patient's interest (create motivation) d. Allow time to evaluate patient understanding of teaching presented e. Prioritize what is more important to teach before teaching less important information
all of them
A client is prescribed disulfiram to support him in remaining alcohol free. Which of the following must he avoid contact with in order to reduce the risk of unwanted side effects of the medication? a. purine b. alcohol c. tyrosine d. tyramine
b
A client with a diagnosis of major depression and a recent suicide attempt states, "I should have died. Nothing every goes right for me." Which response would be considered therapeutic? a. "These are normal feelings when you are depressed." b. "You've been feeling this way for awhile?" c. "Why do you see yourself as a failure?" d. "You have everything to live for."
b
A first-trimester client is experiencing nausea and vomiting. Which of the following may be beneficial? a. Sipping cold ginger ale or other carbonate beverage between and with meals b. Eating a protein snack before bedtime and having a dry carbohydrate such as crackers upon awakening before moving. c. Drinking water before and during meals and avoiding water after meals d. Avoiding all carbohydrate foods and simple sugars
b
A full-term, nonmedicated client was 8 cm dilated and at +1 station and using the birthing ball for comfort one hour ago. Now she is writhing in pain and saying, "help me, help me". What is the priority nursing action? a. Asking the client for suggestions on what might make her more comfortable b. Performing a sterile vaginal exam to see if dilation is complete c. Doing a bladder scan to determine if the bladder is distended d. Preparing to administer a narcotic analgesia intravenously
b
A hospitalized 35-year-old male with testicular cancer is joking and playing cards with his friend. When the nurse assesses his pain, he rates his pain as 7 on a scale of 10. The nurse concludes: a. The patient is enjoying the effects of the pain medication b. The patient is in pain and requires medication c. The patient is reacting emotionally to his diagnosis of cancer d. The patient is anticipating pain later and wants medication
b
A laboring client presents to the department with complaint of "leaking" and a temperature of 102.5. What does the nurse anticipate is happening? a. Urinary tract infection b. Intrauterine infection c. A group B stretococcal infection d. Stress response to labor
b
A newborn is very "ruddy" or red at birth. The infant remains very "ruddy" even when sleeping. What laboratory test would the nurse want to evaluate? a. Bilirubin b. Hematocrit c. Sodium d. Glucose
b
A nurse is working on a respiratory care unit. Which of the following actions by the nurse may increase respiratory difficulty for some patients? a. Withholding antibiotic therapy until cultures are obtained b. Wearing perfume or cologne to work c. Encouraging patients to ambulate d. Encouraging patients to increase fiber
b
A patient who has a narrowed airway due to bronchoconstriction will retain carbon dioxide which would cause which of the following problems? a. metabolic alkalosis b. respiratory acidosis c. metabolic acidosis d. respiratory alkalosis
b
A pregnant client presents to the clinic with complaints of blurred vision, seeing halos around lights and lots of glare. The nurse notes a cloudy, white pupil on opthalmic examination. What does the nurse suspect is affecting the client's vision? a. congenital blindness b. a cataract c. presbyopia d. myopia
b
An 18-year-old male was diagnosed with testicular cancer and is scheduled for a radical inguinal orchiectomy with immediate reconstruction. The nurse understands this means: a. The patient will have the affected testicle removed followed by chemotherapy or radiation as needed. b. The patient will have the affected testicle removed with a surgical prosthetic testes inserted to facilitate body image. c. The client has already had chemotherapy and is now scheduled for surgical removal of the affected testicle. d. The client has already had radiation and is now scheduled for surgery.
b
An abused patient is admitted to the emergency department with multiple injuries which she states are the result of not having a meal ready when her husband came home from a hard day at work. Which is the following best describes the situation? a. This response is appropriate acceptance of her responsibility. b. This is a typical response of a victim accepting blame from a c. This response is atypical of an abused woman. d. This response is evident that the patient may be as much at fault for the violence as the abuser.
b
An adolescent client reports dizziness and nausea to the teacher and is sent to the nurse's office. The nurse smells alcohol on the client's breath. Which opening statement/question would be least threatening and help to establish rapport? a. "Did you drink alcohol before you came on campus today?" b. "Tell me what you had to eat and drink in the last 24 hours." c. "Why do you think you are feeling sick this morning?" d. "I know high school can be stressful, but drinking alcohol is not the best way to handle stress."
b
An infant is transported via LifeFlight to a hospital far from his family. Due to distance, family will be unable to visit daily. Which of the following is an important nursing intervention to promote healthy development? a. Ensure the environment is clean and sterile b. Hold, cuddle, and rock the infant often c. Encourage family to visit more often d. Provide crib toys for distraction
b
During a well-child clinic visit, the nurse identifies the child has been struck by a hand. The mother shares the father has hit the child at times while under the influence of alcohol and has now agreed to go to Alcoholics Anonymous. What is the best response by the nurse? a. The nurse allows the mother to take control and that her plan for Alcoholics Anonymous is an effective one. b. The nurse discusses with the mother "failure to protect the child" and that a referral will be made to child protective services. c. The nurse agrees not to get involved provided the father follows through on attending Alcoholics Anonymous. d. The nurse commends the mother for addressing the underlying problem and secretly contacts child protective services.
b
In order to reduce the risk of respiratory distress in a newborn, the nurse will prioritize: a. identifying an Apgar score b. drying the infant thoroughly after delivery c. assessing reflexes d. assessing abdominal movement
b
Solve this ABG: pH 7.23 PaCO2 38 HCO3 15 a. metabolic alkalosis b. metabolic acidosis c. respiratory acidosis d. respiratory alkalosis
b
The most significant complication of the Roux-En-Y procedure is: a. developing gastroesophageal reflux disease (GERD) b. leakage from the surgical anastomoses resulting in infection and peritonitis c. malnutrition due to decreased absorption of nutrients d. loose bowel movements and gassiness following meals
b
The nurse discovers a young school-age child crying when she enters the room to provide a pre-operative medication. Which response is therapeutic? a. "Let me get your doctor. He can help you to know everything is going to be okay." b. "It is okay to cry. This must all feel a little overwhelming." c. "I don't know why you are crying. Typically people cry after surgery, not before." d. "Would you like some toys from the playroom while you wait for surgery?"
b
The nurse is planning physical fitness and exercise recommendations for a 27-year-old pregnant woman at 16 weeks' gestation. The woman states that before becoming pregnant, she ran 3.5 to 4 miles on four days per week at a pace of 11 minutes per mile. She enjoys competing in 5K races and has a goal to complete a 10K race before the age of 30. Which exercise recommendation should the nurse include for this client at this stage of her pregnancy? a. Continue exercising the same amount of time, but decrease the intensity of the workout to a jog or walk b. Continue engaging in activity as much as possible, with a goal of at least 150 minutes of moderate to vigorous activity per week c. Decrease the amount of exercise to 30 minutes three times per week, engaging in moderate to vigorous activity d. Increase the amount of exercise to 60 minutes on most days of the week, most of it aerobic exercise
b
To support growth and development of a fetus, the pregnant woman needs to increase her intake of which of the following nutrients? a. folic acid b. protein c. magnesium d. B12
b
What nutrient is essential for women anticipating pregnancy or becoming pregnant in order to prevent neural tube defects in the fetus? a. Vitamin D3 b. Folic Acid c. Magnesium d. Calcium
b
What nutrients are especially important to promote adolescent growth? a. Melatonin and zinc b. Calcium and protein c. Vitamin D and magnesium d. Folic acid and Vitamin C
b
What would you do for this tracing? (picture of a deceleration) a. Encourage the woman to do slow, deep breaths b. Change the woman's position c. Initiate oxytocin infusion d. Encourage the woman to pant-blow patterned breathing
b
When caring for an LGBTQ adolescent, the nurse is aware that these adolescents are: a. more likely to seek regular healthcare as well as reproductive healthcare b. more likely to be suicidal and/or homeless than other adolescents of the same age c. more likely to be sexually active at a younger age and dress provocatively d. more likely to be caring relationships with little risk of violence
b
When preparing to teach adolescents the dangers of smoking and encourage don't start and/or stop now; what materials would best fit the needs of adolescents? a. Lecture with games, activities, and interaction between participants highly encouraged. b. Audiovisuals, peer educators, group discussions, and activities. c. Lecture with colorful handouts to share with parents and a website for more information. d. Poll the adolescents at the start of the presentation and do it how they want it to be done.
b
Which answer is best when a mother expresses concern about her newborn's "yellow eyes"? a. "Your infant may just be having a harder time transitioning than others." b. "Jaundice sometimes occurs in newborns because of increased levels of bilirubin; we may need to do check a blood sample." c. "A newborn's liver is immature. You have nothing to worry about." d. "Your infant may be developing kernicterus. I will notify the doctor immediately."
b
Which is most concerning in a newborn? a. Extra digit on the fifth digit of the left foot b. No urine voided in the first 24 hours of life c. Meconium passage with every void d. Positive tonic-neck reflex
b
Which newborn infant is most at risk for becoming jaundiced? a. Term infant who is bottle-fed formula every 3-4 hours b. Premature infant with a large cephalohematoma c. Term infant who breastfeeds every 2-3 hours d. Preterm infant delivered by C-section
b
Which newborn is most concerning? a. Newborn with negative Ortolani's sign b. Newborn with circumoral cyanosis and nasal flaring c. Newborn with acrocyanosis and a respiratory rate of 57 breaths per minute d. Preterm newborn who failed initial hearing screening
b
Which of the following is considered a presumptive sign of pregnancy? a. Fetal movement felt by examiner b. Missed period and breast tenderness c. Cervical softening with bimanual pelvic examination d. Visualization of fetus on ultrasound
b
Which of the following pregnant clients requires priority teaching to prevent possible fetal harm? a. Client who practices yoga and swims 3 times a week in a public pool b. A client who gardens and eats homegrown vegetables. c. Client who has gained four pounds from baseline. d. Client who has a thin, milky vaginal discharge
b
Which of the interventions below would most effectively reduce the risk of cold stress and respiratory depression? a. Obtain a glucose measurement via heelstick. b. Dry the infant thoroughly, place in mother's arms and encourage breastfeeding. c. Bathe immediately after delivery and wrap in warm blankets. d. Dry the infant thoroughly and place under the radiant warmer for observation.
b
Which response is therapeutic when a client states, "I haven't slept for several nights"? a. "Sometimes I have a hard time sleeping too." b. "You are having difficulty sleeping?" c. "Really?" d. "Hmmm..."
b
You would teach a patient the importance of attaching __________________________________before self-administering a dose of medication via metered dose inhaler (MDI). a. a peak flow meter b. a spacer c. an oxygen flow meter d. a nebulizer
b
SA*** During the first year of life, which foods will be included/offered? Select all that apply. a. Whole milk from a cow b. Breast milk or formula c. Food made for babies with no added sugars d. Restrict foods to those which can be fed on a spoon e. Table food cut to reduce risk of choking
b, c, e
What clinical manifestations would you expect to observe in an asthma attack? Select all that apply. a. pursed lip breathing b. dyspnea c. barrel chest d. wheezing e. clubbed fingertips f. cough
b, d, f
SA*** Which of the following may trigger asthma? Select all that apply. tile floors a. tile floors b. cigarette smoke c. indoor pets d. stuffed animals e. carpet and pillows f. allergies
b,c,d,e,f
SA**** A client is 8 centimeters dilated and has chosen to have no medical interventions for pain. Her partner states, "She is so irritable. What can I do? "Which of the following would the nurse suggest? Select all that apply. a. "Perhaps she should start pushing. That might help with the pain." b. "Continue to praise her effort and give her positive encouragement." c. "The most effective thing you can do is just to be present with her. She really needs you." d. "Let me call your doctor. She should receive medication immediately." e. "Encourage your partner to rest between contractions."
b,c,e
SA**** What nursing interventions are indicated to reduce the risk of complications following gastric bypass surgery? Select all that apply. a. Limit dietary intake indefinitely to plain water. b. Encourage the patient to sit up in a chair at the bedside three times daily. c. Instruct the patient to use the incentive spirometer ten times each hour while awake d. Obtain and evaluate vital signs every hour during hospitalization. e. Initiate ambulation as soon as a physician's order is obtained for up as tolerated
b,c,e
A 21-year-old male athlete presents to the emergency department complaining of excruciating pain in his groin. He denies having a sexual partner at this time, has no penile discharge or penile sores, and has no fever. Upon examination the nurse observes scrotal swelling, unilateral erythema, and pain and tenderness with palpation of 10/10. The nurse anticipates which of the following? a. Obtaining a blood sample to test for sexually transmitted infections. b. Obtaining a urine sample to test for the presence of chlamydia. c. Preparing the patient for immediate surgery. d. Swabbing the penis to obtain a sample for culture and sensitivity.
c
A 34 year old client with a long history of endometriosis with painful periods and six laparascopic surgeries to remove the endometrial tissue, asks, "I can't take this anymore." Which birth control option might be pertinent to discuss at this time? a. oral contraceptive pills b. diaphragm or other barrier device c. hysterectomy d. an intrauterine device (IUD)
c
A 70-year-old patient has not been taking medications to control hypertension. When questioned, the patient states his son controls his bank account and he doesn't have enough money to buy his medications currently. What is this an example of? a. Physical abuse b. Physical neglect c. Economic abuse d. Psychological abuse
c
A client at 16 weeks gestation is scheduled to receive a cervical cerclage due to a history of cervical insufficiency. Which statement by the staff nurse would cause the charge nurse to intervene? a. "Notify your healthcare provider if you experience any low back pain or pelvic pressure." b. "Your healthcare provider will tell you when or if it is safe to resume sexual intercourse." c. "You will have a contraction stress test after the procedure to determine how the fetus is doing." d. "Once you have been able to void and are able to ambulate safely, you will be discharged to home."
c
A client comes to the clinic and describes she has been experiencing abuse for the last three years and is ready to leave her partner, but has no idea what to do next. Which nursing intervention is appropriate in this situation? a. Reinforce concern for the client's safety and support for her decision. b. Communicate acceptance and praise the client's decision. c. Assist the client to explore available options including shelters and legal protection. d. Provide the client with a phone number of the nearest emergency shelter.
c
A client comes to the emergency room with sudden onset severe right lower abdominal pain and dizziness. What assessment findings would the nurse anticipate finding if there was a ruptured ectopic pregnancy? a. Crackles with lung auscultation b. Distended jugular veins c. Low blood pressure and tachycardia d. Pulse of 60 beats per minute
c
A client is 41 weeks and is admitted in true labor. Which fetal heart rate monitoring pattern is reassuring? a. Multiple late decelerations with minimal beat-to-beat variability b. Variable decelerations are becoming more frequent with 3 in the last ten minutes c. Spontaneous accelerations with activity; fetal heart rate increases 15 beats per minute lasting at least 15 seconds d. Late decelerations are occurring with over 50% of the contractions
c
A client is diagnosed with complete placenta previa. What would the nurse anticipate discussing with the patient? a. Weekly transvaginal ultrasounds b. Clearance for sexual activity once the bleeding stops c. Scheduling a date for cesarean section prior to onset of labor d. Weekly vaginal speculum examinations
c
A client states, "My teenage daughter keeps coming home long after the curfew she has been given. I can't sleep at night worrying that she will get pregnant." The nurse states, "Hang in there. She is just trying to find herself right now. Adolescence is tough." Which communication block did the nurse make? a. Belittling the client b. Requesting an explanation c. Stereotypical comments d. Probing more deeply
c
A client's obstetric history is recorded as G5T1P2A1L2. Which statement is correct? a. The client has had three pre-term births. b. The client is currently not pregnant. c. The patient had has one term birth. d. The client gave birth to triplets.
c
A female client comes to the clinic with complaints of heavy menstrual bleeding and a feeling of fullness in her abdomen. Bi-manual examination by the primary care provider reveals multiple uterine fibroids. Which of the following diagnostic tests would the nurse anticipate being ordered? a. Pregnancy test b. Liver function test c. Complete blood count d. Urinalysis
c
A laboring woman has decided to have an epidural. What would the nurse do to reduce the risk of hypotension following administration of the epidural? a. Position the patient supine with legs raised b. Assist in rupturing the membranes to speed up labor c. Administer the prescribed IV fluid bolus prior to initiation of the epidural d. Administer oxygen via mask at 10 liters
c
A male client reports he rarely brings his partner to satisfaction as he experiences orgasm as soon as he enters the vagina. What is the name of this medical disorder? a. impotence b. erectile dysfunction c. premature ejaculation d. erectile failure
c
A maternity nurse is providing anticipatory guidance to a new mother. Based on Erikson's stages of development, which instruction would be most appropriate? a. If care was provided, infant can safely cry unattended for 10 minutes b. Allow the infant to cry and if it doesn't resolve then attend to the needs c. Anticipate the infant's needs and seek to meet them quickly d. Always wait for the infant to signal a need
c
A new mother is breastfeeding and the nurse notes the infant has only a small amount of the areola in the mouth. The nurse instructs the mother to place a finger in the infant's mouth and detach the infant. Why did the nurse stop the mother from nursing? a. The mother was not breastfeeding properly b. The position of the infant at the breast was wrong c. The small amount of areola will cause increased soreness for the mother d. The infant was not getting enough breastmilk
c
A newborn infant in respiratory distress will have a. delayed capillary refill b. rhinorrhea c. nasal flaring d. a barrel chest
c
A newborn infant's respiratory rate is 80 breaths per minute. What should the nurse do? a. Plan to administer a bronchodilator and a corticosteroid. b. Administer oxygen via nasal cannula at 5 L per minute. c. Hold any infant feedings and notify the primary care provider. d. Elevate the head of the bed to 90 degrees and maintain NPO.
c
A newborn is 48 hours old and has not passed any meconium. What would be the nurse be most concerned about? a. Failure to thrive b. Jaundice c. Gastrointestinal defect d. Constipation
c
A newborn is diagnosed with jaundice. Which intervention is a priority? a. Obtaining blood pressures on all four extremities every four hours b. Keeping the infant NPO to avoid risk of aspiration c. Covering the eyes to avoid exposure to ultraviolet light d. Weighing every four hours
c
A normal newborn respiratory rate is between a. 25-50 breaths per minute b. 15 and 40 breaths per minute c. 30 and 60 breaths per minute d. 20-80 breaths per minute
c
A nurse is preparing a patient for the termination phase of the nurse-patient relationship. Which nursing task is appropriate to this stage of the relationship? a. Identifying rules and roles b. Setting short term goals c. Identifying outcomes achieved d. Setting expectations
c
A patient is being transferred from the surgical gurney to the postoperative bed following gastric bypass surgery and the nasogastric tube (NG tube) is inadvertently pulled out. What nursing intervention is indicated? a. Immediately reinsert the NG tube and secure in place. b. Gather the materials and then ask the charge nurse to reinsert the NG tube. c. Sit the patient up in high Fowlers position until the surgeon can reinsert the NG tube. d. Settle the patient comfortably in bed and then notify the surgeon to reinsert the NG tube.
c
A preadolescent client who fell from a balance beam in physical education class injured her ankle. Given this information, which action by the school nurse is appropriate? Group of answer choices a. Planning for a corticosteroid injection b. Ordering an x-ray of the ankle c. Placing an ice pack on the client's ankle d. Referring the client to physical therapy
c
An HIV positive client becomes pregnant. Which information is appropriate to include in patient teaching? a. The rubella vaccine is indicated at this time b. The tetanus-diptheria-pertussis vaccine is indicated at this time c. Prescribed antiretroviral therapy should be continued during pregnancy to reduce the risk of transmission to the infant d. The infant should be fine and will not require treatment after birth
c
An adolescent female is dilated to 2 cm and 50% effaced. Her membranes are intact and contractions are 5 to 6 minutes apart lasting 45 seconds. Which nursing intervention is recommended at this time? a. Encourage the client to sit in a chair and put her feet up on a stool b. Encourage the client to remain in a left-side-lying position c. Encourage the client to ambulate in the hallway d. Encourage the client to lie in whatever position is comfortable
c
An adult usually has respirations between a. 10 and 30 per minute b. 20 and 40 per minute c. 12 and 24 per minute d. 30 and 60 per minute
c
An elderly client has been taken care of by the same home health nurse for many years. The nurse notes that the client is more withdrawn and states she doesn't leave home much anymore as her children who live near her are just "too busy". She then reminisces about how they used to take her to dinner, to theater, and to church each and every Sunday. Which of the following is the priority at this time? a. The nurse should reassure the client that normal aging precludes being able to get out and about. b. The nurse should identify community resources which would allow her to be more active in the community. c. The nurse should assess the client further as this may indicate possible abuse or neglect by her adult children. d. The nurse should request the phone numbers of the children and contact them immediately
c
At what age does regular dental care begin? a. When there are visible signs of injury to the enamel b. When solid foods are eaten and teeth begin to become stained c. When the first tooth erupts or no later than 18 months of age d. When all primary teeth have erupted
c
Chronic use of antacids may cause which of the following? a. nausea, vomiting, and bloody stools b. steatorrhea and halitosis c. diarrhea or constipation or kidney stones d. hematemesis
c
Failure to thrive: a. has no long term complications b. usually has an easily identified underlying cause c. is usually related to inadequate caloric intake, malabsorption, or an increase in caloric needs that is unmet d. affects only children in lower socioeconomic classes
c
Holistic patient-centered care results in: a. Cost savings and decreased risk of illness or disease b. Skepticism of the medical community and decreased use of medical services c. Individualized care and improved patient outcomes d. Less use of medical interventions and increased use of alternative medicine
c
In order to reduce the risk of respiratory distress in a newborn, the nurse will prioritize: a. assessing reflexes b. assessing abdominal movement c. drying the infant thoroughly after delivery d. identifying an Apgar score
c
Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily disfigurement from severe burns over the trunk and arms, is being seen in the clinic for his chronic pain. Which evaluation criteria would indicate treatment is effective? a. Mr. Lim reports decreased appetite and energy b. Mr. Lim reports satisfaction in his marriage and other relationships c. Mr. Lim reports sleeping 5 hours a night and thinking about returning to work d. Mr. Lim reports disturbed sleep and increased appetite
c
Solve this ABG: pH 7.46 PaCO2 47 HCO3 32 a. respiratory alkalosis b. metabolic acidosis c. metabolic alkalosis d. respiratory acidosis
c
The client's last menstrual period started March 1st and ended March 5th. Using Nagele's rule, what is the estimated date of birth? a. December 22 b. December 30 c. December 8 d. December 12
c
The most effective treatment for infantile gastroenteritis is: a. obtaining culture and sensitivity testing and initiating broad spectrum antibiotics b. hospitalization, nothing by mouth, and normal saline intravenous infusions c. drinking small, frequent amount of healthy liquids such as oral rehydration formulas, breast milk, or infant formula d. alternating ibuprofen and acetaminophen every four hours for ten days
c
The nurse is caring for a patient who is attempting a trial of labor after cesarean (TOLAC) because she would like a vaginal birth after cesarean (VBAC). She is experiencing contractions that last 75-90 seconds and are 2-3 minutes apart. The patient complains of "sharp, tearing pain" and the nurse notes an absence of contractions on the monitor. What is the priority nursing action? a. Prepare to insert an internal fetal scalp electrode b. Reposition the client c. Prepare for emergency cesarean birth d. Perform a sterile vaginal examination to assess effacement
c
The nursing student understands which of the following is true of domestic violence? a. Domestic violence is rarely triggered by pregnancy b. Underlying substance abuse is always a contributing factor c. It occurs across all socioeconomic levels d. Those who struggle financially are at highest risk for domestic violence
c
What do condoms provide that other methods of birth control do not? a. Protection from pelvic inflammatory disease b. Protection from pregnancy c. Protection from sexually transmitted infections d. Protection from dysmenorrhea
c
What is the nurse observing in this tracing? (FHR decel delayed compared to contraction) a. Variable decelerations b. Early decelerations c. Late decelerations d. Normal fetal heart rate
c
When a 16-year-old is hospitalized, which intervention is appropriate to support developmental growth (Erikson) ? a. Do not allow visitation until he fully accepts and adjusts to his new diagnosis b. Encourage his religious leader to visit and listen to his concerns c. Encourage his family to have his similar age friends visit d. Force the adolescent to complete school work daily so he does not fall behind
c
When an adolescent is hospitalized, the major threat felt will be related to which of the following based on Erikson's stages? a. Separation anxiety b. Loss of bodily control c. Altered body image d. Fear of the unknown
c
When assessing a child for pain, a good guideline would be: a. The parent's observations should always be included in the pain assessment b. Consulting a parent is mandatory before medicating a child c. If it causes pain for an adult: it will cause pain for a child d. Listening to the parent will always result in the right amount of medication for the child
c
When caring for an adolescent post-surgery, which teaching statement is best to use for an adolescent? a. "Do everything just as instructed to avoid having conflict with your parents." b. "Trust me. You need to do everything just as I tell you." c. "Following these discharge instructions will enable healing that allows you to get back to your normal activities." d. "You must follow these instructions to prevent future complications."
c
When in the therapeutic nurse-patient relationship is a patient most likely to share frustrations and feelings? a. Termination phase b. Orientation phase c. Working phase d. Preparation phase
c
When providing care for a patient undergoing gastric bypass surgery, the nurse must anticipate: a. disordered eating, non-compliance with the care regimen, and potential for conflict with other patients and staff members b. minimal care will be needed as the patient should be encouraged to do all that he can for himself c. what bariatric equipment may be indicated for patient safety and dignity and having it available in the room d. the patient will have a disturbed body image and require psychiatric inpatient are
c
Which communication technique is considered therapeutic? a, Offering advice and opinions to the client/patient b. Sharing personal information with the client/patient c. Using open-ended questions and silence d. Documenting patient and family interactions
c
Which description accurately defines the relationship between biologic gender and sexual identity? a. Sexual identity is based on those you find sexually attractive while gender is determined at birth b. Nurses use these words interchangeably as they mean the same thing c. Gender is determined at birth, but sexual identity is a psychosocial construct d. Biologic gender and sexual identity are both chromosomal
c
Which is true of health issues in the LGBTQAI population? a. Lesbians and bisexuals are more likely to be underweight and/or anorexic b. Queers live healthier lives and are less likely to abuse alcohol or other drugs c. LGBT youth are more likely to attempt suicide d. Lesbians are more likely to obtain preventive healthcare services
c
Which method is correct for obtaining a blood specimen from a newborn? a. Warm the hand and obtain a sample from a fingertip. b. Warm the foot and obtain a sample from the heel. c. Warm the foot, clean it with an alcohol prep pad, and puncture the side of the heel. d. Apply a tourniquet to the upper extremity and obtain a blood sample via venipuncture.
c
Which of Erikson's stages is when social relationships outside the family and individual productivity first begin to increase? a. Autonomy versus Shame and Doubt b. Generativity versus Stagnation c. Industry versus Inferiority d. Regression and Remorse
c
Which of the following is a warning sign of dehydration in an infant? a, temperature of 98.6 b. respirations of 45 c. depressed anterior fontanel d. heart rate of 140
c
Which of the following is a warning sign of dehydration in an infant? a. temperature of 98.6 b. heart rate of 140 c. depressed anterior fontanel d. respirations of 45
c
Which of the following is most concerning in a newly admitted laboring woman? a. Total weight gain of 30 pounds b. Maternal age of 32 c. Blood pressure of 146/90 d. Treatment for chlamydia at 15 weeks
c
Which of the following would provide the greatest protection from sexually transmitted infections? a. Condoms and spermicide b. Monogamous relationships c. Abstinence d. Condoms and lubricant
c
Which statement indicates a new mother has understood breastfeeding instructions? a. "I will feed my infant whenever he wakes up." b. "I will breastfeed and supplement with formula every 3 hours until my milk comes in." c. "I will breastfeed my baby every 2-3 hours." d. "I will need to wean my infant by six months so I can start iron-fortified formula."
c
Which statement is true about menstruation? a. Menstruation is always an uncomfortable, debilitating experience b. Menstruation is when a woman is most fertile c. In a 28 day menstrual cycle, menstruation lasts approximately 3-5 days d. Absence of menstruation always indicates pregnancy
c
You are called to the emergency room with a multiple trauma situation where a tour bus has rolled and there are incoming casualties. In addition to ensuring patients are triaged quickly and receive treatment, what is an additional priority to consider? a. Ensure the unit secretary is calling in additional off-duty staff members to manage the increased demands b. Quickly identify which patients can be safely discharged to clear space for new admissions c. Determine if the injured are English speaking and arrange for medical interpreters if needed d. Obtain additional equipment and supplies to meet the demands of increased patient load
c
SA*** A patient comes to the clinic complaining of "heartburn". What symptoms as described by the patient cause the nurse to think the patient is experiencing gastroesophageal reflux disease (GERD)? Select all that apply. a. Frequent loose diarrhea-type stools b. Frequent nocturia and night awakenings c. Pain is usually relieved with antacids d. Coughing or regurgitation while sleeping e. Pain and discomfort around the upper abdomen following meals
c,d,e
A 41 week pregnant woman comes to the office for her regularly scheduled prenatal visit. Which client statement would be most concerning? a. "I am really enjoying sex with my partner!" b. "I have a hard time breathing when I bend over to tie my shoes." c. "I have noticed a clear to milky-white discharge from my vagina the last few days." d. "I am thinking it must be getting pretty cramped in there as the baby doesn't seem to move much."
d
A 65-year-old client comes to the clinic complaining of constipation that developed recently and just seems to be getting worse rather than better. The nurse anticipates the primary care provider will order: a. metabolic screening testing to assess for malnutrition b. labwork to check for anemia and malnutrition c. a consult with a surgeon for an exploratory laparotomy d. a diagnostic colonoscopy due to his age and presenting symptoms
d
A child is scheduled for major invasive surgery. The child's mother states she does not want her child to receive narcotics postoperatively. What is the nurse's best response? a. "The pain will be significant. Should we discuss your decision with your child?" b. "Sure, no problem. I will relay your request to the healthcare team. I believe in advocating for what patients and families want." c. "You do not have a choice in the medications your child receives. The surgeon makes all those decisions independently." d. "Your child's pain will be significant after surgery. Please tell me more about not wanting your child to have narcotics."
d
A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, what laboratory test does the nurse anticipate the primary care provider will order? a. urinalysis b. human chorionic gonadotropin level c. urine specific gravity d. hemoglobin and hematocrit
d
A client comes to the emergency room at 36 weeks gestation complaining of epigastric pain, nausea, and a pounding headache. Which laboratory finding does the nurse anticipate? a. increased serum creatinine levels b. low hemoglobin c. urine culture positive for E. coli d. elevated liver enzymes (aspartate aminotransferase= AST)
d
A client comes to the obstetric clinic stating she missed her period, had a positive home pregnancy test, and is now experiencing abdominal pain. The nurse notes the client has a history of endometriosis, chlamydia, and a family history of alcoholism. The nurse suspects which of the following? a. polycystic ovarian syndrome b. liver enlargement c. pelvic inflammatory disease d. ectopic pregnancy
d
A client from another country routinely consults with her mother before verbalizing her own healthcare decisions. What action by the nurse is appropriate? a. Ask the client why she is consulting her mother for every decision. b. Ask the client's mother to leave the room to provide the patient for privacy when making healthcare decisions. c. Speak to the mother outside the room and explain the patient is old enough to make her own independent decisions. d. Accept the behavior as the client is still voicing her own decisions.
d
A client has been injured in an accident and needs treatment for an arm fracture. The client has a history of substance abuse and requests only acetaminophen for pain. The provider orders the nurse to administer narcotics for pain due to the fracture. Which best describes the first step of the nurse in managing this situation? a. Tell the client the medication must be taken as it is prescribed b. Asking the charge nurse to get the healthcare provider to change the order c. Helping the client to find a support group to help manage conflict associated with taking drugs for pain d. Teaching the client about the importance of managing pain for an injury to promote healing versus using drugs inappropriately
d
A client has expressed a desire to give birth with minimal interventions. She is currently dilated to 7 cm and 100% effaced with membranes intact. Which intervention would be appropriate? a. Administering opioid analgesia intravenously b. Waiting to see if the membranes rupture c. Discussing the availability of epidural analgesia d. Offer support by reviewing and working with her on comfort strategies she previously identified
d
A client in active labor asks, "Why are you monitoring my blood pressure so frequently?" What would be the most appropriate response by the nurse? a. "It's just our standard policy. We do it all the time." b. "We are concerned about low blood pressure which could make you dizzy or faint." c. "We are making sure you are not developing pre-eclampsia." d. "We are monitoring as changes in your blood pressure may affect the fetus."
d
A client in early labor with an external fetal monitor states she needs to go to the bathroom. She has no restrictions on her activity in the chart. What is the most appropriate action? a. Assist her to use a bedpan so she doesn't need to get out of bed. b. I have no idea. Why are these questions so hard? c. Request an order for a urinary catheter so she does not need to get out of bed. d. Assist the patient to ambulate to the bathroom.
d
A client is admitted with pelvic inflammatory disease. Which position is indicated to facilitate pain relief and vaginal drainage? a. Sim's b. Prone c High Fowler's d. Dorsal recumbent
d
A client presents for her first prenatal visit at 14 weeks. Which of the following would findings would require additional follow-up? a. Urine is negative for nitrates and ketones b. Urine is negative for glucose and ketones c. Fetal heart rate by Doppler is 140 beats per minute d. Uterine fundus is at the level of the umbilicus
d
A client states, "I am going to die and I wish my family would stop hoping for a cure. I get so angry when they act like this. After all, I am the one who is dying. I should get to do it my way." Which response is most therapeutic? a. "You are probably feeling depressed and that makes you angry." b. "It shouldn't make you angry that your family continues to hope for a cure. They love you." c. "Let's talk more about feeling angry." d. "Tell me what happens when you try to share your feelings with your family."
d
A female client confides to the nurse that she and her partner enjoy anal intercourse. What information would the nurse provide? a. Anal intercourse should be avoided b. Lubricants should be avoided c. Rectal mucosa is thick and can withstand vigorous activity d. Condoms are recommended for anal intercourse
d
A laboring woman is receiving oxytocin augmentation to increase duration, intensity, and frequency of contractions. When her cervix is dilated to 6 cm, her membranes spontaneously rupture with meconium stained amniotic fluid. What is the priority action by the nurse? a. Check the fluid with nitrazine paper to make sure it is amniotic fluid b. Increase the rate of the oxytocin infusion c. Position the client in lithotomy position d. Assess the fetal heart rate
d
A maternity nurse is providing anticipatory guidance to a new mother. Based on Erikson's stages of development, which instruction would be most appropriate? a. If care was provided, infant can safely cry unattended for 10 minutes b. Allow the infant to cry and if it doesn't resolve then attend to the needs c. Always wait for the infant to signal a need d. Anticipate the infant's needs and seek to meet them quickly
d
A mother is preparing to breastfeed her newborn. She calls the nursery and states, "My baby seems to be breathing rapidly and his nose is flaring out. He looks kinda weird." What should the nurse do? a. Reassure the mother that nasal flaring is normal as newborns are obligate nose breathers b. Assist the mother to position the infant at the breast and assess the LATCH score c. Teach the mother to use the bulb syringe and suction the mouth and then the nose d. Assess for nasal flaring, work of breathing, and pulse oximetry values
d
A newborn infant in respiratory distress will have a. a barrel chest b. delayed capillary refill c. rhinorrhea d. nasal flaring
d
A newborn infant's respiratory rate is 80 breaths per minute. What should the nurse do? a. Elevate the head of the bed to 90 degrees and maintain NPO. b. Plan to administer a bronchodilator and a corticosteroid. c. Administer oxygen via nasal cannula at 5 L per minute. d. Hold any infant feedings and notify the primary care provider.
d
A nurse is providing wellness teaching to a client who is interested in beginning an exercise program to reduce certain health risks. The nurse determines that the client understands the teaching when the client selects which health risks that can be reduced by regular exercise? a. Type 1 diabetes b. Liver disease c. Renal disease d. Cardiovascular disease
d
A patient has come to the emergency room for multiple physical complaints. Diagnostic testing has been completed and does not reveal disease or disability. The patient now comes to the clinic and expresses multiple physical complaints. What should the nurse do? a. Express doubt and concern about the patient's repeated physical complaints. b. Reinforce that testing has been completed and there is nothing more that can be done. c. Reinforce that all testing has been done and nothing is wrong. d. Update patient history and complete a thorough physical assessment.
d
A patient is newly diagnosed with gastroesophageal reflux disease. What health promotion activities would the nurse suggest? a. Lie down on the right side for 30 minutes after meals b. Lie down on the left side for 30 minutes after meals c. Sleep supine with the head of the bed flat d. Remain upright for 2-3 hours after meals
d
A patient is prescribed salmeterol (a bronchodilator) and fluticasone ( a glucocorticoid corticosteroid). In which order should these medications be taken? a. Fluticasone followed by the salmeterol. b. It doesn't matter. They will work in any order. c. Whichever is used first should always be used first. d. Salmeterol first followed by the fluticasone
d
A patient who appears to be physically in pain refuses pain medication. Which action is appropriate? a. Consult with the health care provider if there is a way to provide medication in a different way or without the patient's knowledge. b. Continue to monitor the client and document findings in the medical record. c. Ask the patient if there is a family member who would be able to come and explain the situation more effectively to him. d. Assess the patient's understanding of treating pain in order to promote healing.
d
A patient who smokes 1 pack per day with a 30 year pack history, obesity, frequent heartburn, history of peptic ulcers, and intermittent constipation asks the nurse what is the most important thing he can do to "get healthier". What would the nurse advise? a. Exercise daily b. Increase daily water intake c. Lose ten percent of body weight d. Stop smoking
d
A pregnant client is 20 weeks pregnant. Where does the nurse anticipate being able to palpate the uterine fundus? a. A few centimeters above the symphysis pubis b. At the level of the symphysis pubis c. A few centimeters above the umbilicus d. At the level of the umbilicus
d
A pregnant nurse needs an appropriate patient assignment. Which patient would be most appropriate? a. Client with a high fever and herpes simplex meningitis b. An immunocompromised client with rubella related encephalitis c. Client with congenital cytomegalovirus infection and purpuric rash d. Septic client with staphylococcus aureus
d
A three year old is constantly rebelling and throwing tantrums, the nurse provides guidance by stating which of the following? a. Punish the child for every misbehavior b. Demand the child be respectful and acknowledge authority c. Ignore the behavior and consider it normal d. Provide appropriate choices, set limits, and provide boundaries
d
Along with Erikson's stages of psychosocial development, it is important to assess gross and fine motor development as well. Which of the following tests is used to assess development in children? a. Mini mental status exam b. Braden score c. Apgar score d. Denver Developmental Standardized Test
d
An adolescent presents at the clinic for healthcare. Which question will elicit the most information? a. How many sexual partners have you had? b. Are you involved in an intimate relationship at this time? c. Have you ever been diagnosed with a sexually transmitted infection? d. What questions or concerns do you have about your sexual health?
d
Children with failure to thrive: a. often have parents who are neglectful or abusive b. are difficult to console and hard for parents to love and care for c. usually need inpatient hospitalization to treat medical and psychological needs d. are generally best treated in their own homes where they feel secure rather than being hospitalized
d
Failure to thrive : a. usually affects children less than 1 year of age b. is simple to diagnose and easily treated c occurs across the lifespan and affects adolescents the most d. may be caused by organic or inorganic factors or a combination
d
If a child is hospitalized due to failure to thrive, the nurse recognizes: a. the environment the child lives in must be rat-infested and unlivable b. the safest place for any child is in the hospital where skilled professionals can provide round the clock care c. the parents are unsafe, negligent, or abusive d. the child's failure to thrive has become potentially life threatening
d
The nurse desires to improve competency in caring for families within the LGBTQAI community. Which first step should the nurse take to improve this competency? a. Build cultural and personal knowledge b. Learn the relevant terminology and preferred terms c. Develop an understanding of the unique healthcare disparities d. Evaluate personal background, beliefs, and implicit biases
d
The nurse is caring for a woman who went through menopause 5 years earlier. The nursing plan of care for this patient includes teaching related to the importance of what dietary change? a. increased fluid intake b. increased intake of fatty foods c. increased fiber intake d. increased calcium and vitamin D3 intake
d
The nurse is preparing to teach a client how to safely ambulate with crutches following surgery. Which principle of teaching and learning is most important? a. Ensure the client understands the proper height of the crutches b. Ensure the client knows not to have their axillae rest on the crutch pads to reduce the risk of injury c. Gather all materials and plan the teaching presentation d. Identify an appropriate time to provide the instruction when the client is alert and prepared to learn
d
The nurse is providing discharge instructions to a patient who recently underwent a bariatric surgery procedure. What instructions would be most important to prevent complications? a. Sit up for three hours after each meal b. Follow the dietary restrictions with exactness to achieve the best results. c. Eating sugar is perfectly fine as long as it is eaten in moderation. d. To avoid dumping syndrome, lie down on the left side for 30 minutes following meals
d
The nurse is teaching middle-age adults how to promote health throughout the lifespan. Which three things will be emphasized as part of the teaching presentation? a. scales, weights, and mirrors b. beds, breakfasts, and behaviors c. nutrition, naps, and nighttime routine d. fluids, fitness and fiber
d
Tubal ligation and vasectomy are considered which of the following methods of birth control? a. Natural family planning methods b. Fertility awareness methods c. Barrier methods d. Sterilization methods
d
What comfort measures might a nurse suggest for a patient with morning pain from osteoarthritis? a. Taking non-steroidal anti-inflammatory medications as prescribed b. Taking corticosteroids as prescribed c. Taking ibuprofen 800 mg by mouth three times daily with food d. A warm bath or shower first thing in the morning
d
What symptoms are associated with gastroenteritis? a. constipation and hard, pellet-like stools b. aganglionic megacolon and bowel obstruction c. abdominal rigidity and tenderness d. diarrhea, cramping, and abdominal pain
d
What would a nurse teach parents to prevent injuries in children? a. Safety proofing all outlets will prevent injuries. b. Avoid using buckets for mopping floors to prevent drowning c. Keep the car seat facing the rear until the child reaches 5 years of age. d. Use recommended safety equipment including car seats, seat belts, helmets, knee pads, etc.
d
When caring for a client with alcohol withdrawal, what is the nursing priority? a. Discussing possible triggers for alcohol use and how to reduce the dependence on alcohol. b. Providing emotional support when the client experiences tactile hallucinations c. Encouraging the client to recognize the negative consequences of alcohol. d. Monitoring and treating effects of central nervous system stimulation
d
When does the first stage of labor end? a. when the fetus is delivered b. when pushing is initiated c. when the placenta is delivered d. when the cervix is fully dilated and effaced
d
When interviewing a patient/client for the first time, which non-verbal behavior strategy should the nurse employ? a. Maintain an open posture with arms folded across the chest b. Maintain indirect eye contact with the patient/client c. Sit squarely within 2 feet of the client d. Ensure verbal and non-verbal responses are congruent
d
When teaching a sexual education to a group of adolescents, the nurse is communicating information about the incidence of sexually transmitted infections (STIs) and the impact on public health. Which is the fastest-spreading bacterial STI in the United States? a. Herpes b. Trichomoniasis c. Gonorrhea d. Chlamydia
d
When working with an adult over the age of 40, what would be essential to improve visual acuity? a. Testing hearing b. Prescription eye glasses c. Distraction free environment d. Adequate lighting
d
Which activity will be most effective in meeting the developmental needs of an older adult? a. A vigorous social schedule b. Playing card or board games c. Mentoring young children d. A reminiscence group
d
Which age group is at highest risk for testicular cancer and requires patient teaching for self-examination to promote early identification and treatment? a. Pre-pubescent males b. Older males c. Pubescent males d. Ages 16-35
d
Which behavior is most alarming in a newborn and should be reported immediately? a. Upper extremities are flexed and brought in close to the face b. Thick greenish-black stools c. Continuous crying while being bathed d. Asymmetrical upper body movements
d
Which client is most concerning? a. Gestational diabetic patient with hemoglobin A1C of 6 b. Second trimester client with dysuria and urinary frequency c. Second trimester client with obesity who can't feel her baby moving d. Third trimester client with hypertension complaining of epigastric and right upper quadrant pain
d
Which client statement indicates a knowledge deficit associated with substance use? a. "Addiction to stimulants like cocaine can occur very rapidly." b. "Alcohol is probably the most widely abused drug." c. "Moderation in all things is always safest." d. "Marijuana is safe and no one can become addicted to it."
d
Which is most concerning in a newborn? a. Absence of retractions b. Respiratory rate of 42 breaths per minute c. Heart rate of 146 per minute d. Umbilical cord with one artery and two veins
d
If failure to thrive is not detected early and appropriate treatment provided, long term lingering effects may occur. True False
true
Immunizations begin shortly after birth and continue throughout the lifespan. True False
true