NURS202 Final
During the fourth stage of labor, the client should be assessed carefully for:
Uterine atony
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment finding would alert the nurse to suspect hypermagnesemia?
Decreased deep tendon reflexes
Which signs and symptoms would lead the nurse to suspect a child has tetralogy of Fallot (TOF)? Select all that apply. -murmur -history of squatting -bounding pulse -cyanosis -faint pulse -tachypnea
-history of squatting -cyanosis -tachypnea -murmur
The nurse is caring for a child with a new diagnosis of diabetes. The nurse teaches blood glucose monitoring by allowing the child to practice checking the blood sugar of a toy bear dressed in a hospital gown. The nurse recognizes this approach to be appropriate for what age level? A. preschool age (3 to 5 years) B. adolescence (10 to 19 years) C. school age (5 to 10 years) D. toddler (1 to 3 years)
A. preschool age (3 to 5 years)
A multigravid client in active labor at 39 weeks gestation has a history of smoking one or two packs of cigarettes daily. Which problem is the nurse most likely to find during the infants assessment?
Low birth weight
Several pregnant clients are waiting to be seen in the triage area of the OB unit. Which client should the nurse see first?
A client at 32 weeks gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain
The nurse is conducting a health history for a client at risk for cancer. Which lifestyle factors considered at risk for colorectal cancer?
A high-fat, low-fiber diet
The nurse is preparing a treatment plan for a child with sickle cell anemia in vaso-occlusive crisis. What is the most important nursing intervention to include? A. Managing pain B. Providing a cool environment C. Immobilizing the affected part D. Restricting fluids
A. Managing pain
A nurse is caring for a toddler in respiratory distress requiring endotracheal intubation. When gathering supplies, which item should the nurse obtain that is most important for this child? A. uncuffed endotracheal tube B. curved blade laryngoscope C. pain medication D. nasogastric tube
A. uncuffed endotracheal tube
When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to wish you the best outcome related to client comfort?
Acute pain
After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal? A. decreases pain at the surgical site B. keeps the new urethra from closing C. measures his urine correctly D. prevents bladder spasms
B. keeps the new urethra from closing
A nurse is caring for a client receiving IV magnesium sulfate. Which drug is the antidote for magnesium toxicity?
Calcium gluconate
A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the clients response, the surgeon should collaborate with which health team member?
Enterostomal nurse
The healthcare provider orders in amniocentesis for a primigravid client at 37 weeks gestation to determine feet along maturity. Which is an indicator of feet along with charity?
Lecithin-sphingomyelin (L/S ratio)
A client with a clamp Sia begins to experience a seizure. Which intervention should the nurse to do immediately?
Maintain a patent airway
A client tell the nurse that she has found a painless lump in her right breast during her monthly self examination. Which assessment finding would strongly suggest that this clients lump is cancerous?
Non-mobile mass with irregular edges
Cowbell to tell the nurse at the clients membrane to rupture" something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action?
Place the mother in a knee-to-chest position
Which intervention should the nurse anticipate using when caring for attorney and he diagnosed with transient tachypnea at two hours after birth?
Provide warm, humidified oxygen in a warm environment
A client is admitted to the hospital for diagnostic testing to rule out colon rectal cancer. Which intervention should the nurse include in the plan of care?
Test all stools for a cold blood
A client with ovarian cancer ask the nurse, "what is the cause of this cancer?" Which is the most accurate response by the nurse?
The risk of developing ovarian cancer is related to environmental, endocrine, and genetic factors
A primivada client is admitted to labor and delivery area, where the nurse evaluates her. Which assessment findings may indicate the need for a cesarean birth?
Umbilical cord prolapse
The nurse is assigned a client with end-stage ovarian cancer with recurrent ascites, and the client is to undergo paracentesis. Which activity is best to delegate to an experienced licensed professional nurse (LPN)?
Vital signs every 15 minutes after the paracentesis
A 52-year-old client is scheduled for total abdominal hysterectomy Pacifico cancer. When discussing the potential impact of this procedure on a client sexuality, how should the nurse respond to the client?
"Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?"
The nurse reviews with the parents how to care for their child with sickle cell anemia at home. The nurse determines that the parents understand the basic principles of home care when they state that they will implement which intervention? A. keeping the child with them at all times B. restricting the child's fluids at night C. encouraging their child to drink as much liquid as possible D. not allowing their child to play with other children
C. encouraging their child to drink as much liquid as possible
A two-year-old child comes to the emergency department with inspiratory stridor and a barking cough. A preliminary diagnosis of croup has been made. What is the nurse's mostimportant intervention? A. administer I.V. antibiotics B. provide oxygen by face mask C. establish and maintain the airway D. ask the parent to go to the waiting room
C. establish and maintain the airway
The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which signs? A. decreased cardiac output with faint peripheral pulses B. profound cyanosis over most of the body C. loud cardiac murmurs through systole and diastole D. harsh systolic murmurs with a palpable thrill
C. loud cardiac murmurs through systole and diastole
The nurse assesses a 2-month old infant with hydrocephalus with a ventriculoperitoneal shunt. The nurse obtains the infant's vital signs. In order to obtain the most significant information about the child's status, which assessment should the nurse make next? A. status of posterior fontanelle B. pupillary reaction to light C. occipital frontal head circumference D. presence of the primitive reflex
C. occipital frontal head circumference
The care of which client can be assigned to an unlicensed assistant personal (UAP)?
A client who is having radiation for cancer of the stomach is to have the radiation site beers with warm water, followed by an application of a moisturizer
A nurse is caring for a client who is receiving chemotherapy for lung cancer. During the hand-off report, the nurse from the previous shift stated the client has been placed on neutropenic precautions. Which laboratory value supports this nursing action?
A white blood cell count of 2200/mm3
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to A. place ice packs on the client's painful joints. B. administer antibiotics. C. provide oral and I.V. fluids. D. administer folic acid supplements.
C. provide oral and I.V. fluids.
A client with human papilloma virus infection is being treated by a colposcopy. The client asked the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur?
Cervical cancer
The nurse provides care to a client with anogenital warts. The nurse teachers that anogenital increase in adolescent females risk of which condition?
Cervical cancer
What is a risk factor for women who have had human papillomavirus?
Cervical cancer
Which factor, if described by the parents of a child with cystic fibrosis (CF), indicates that the parents understand the underlying problem of the disease? A. an abnormality in the body's mucus-secreting glands B. formation of fibrous cysts in various body organs C. failure of the pancreatic ducts to develop properly D. reaction to the formation of antibodies against streptococcus
A. an abnormality in the body's mucus-secreting glands
The nurses discusses appropriate iron-rich food selections with the parent of an 11-month-old infant with iron deficiency anemia. The nurse determines that teaching has been successful when the parent verbalizes that she will include which foods in the child's diet? A. eggs, fortified cereals, meats, and green vegetables B. fruits, cereals, milk, and yellow vegetables C. eggs, fruits, milk, and mixed vegetables D. juices, fruits, fortified cereals, and milk
A. eggs, fortified cereals, meats, and green vegetables
A 4-year-old child is seen at the clinic for a mild iron deficiency anemia caused by a poor diet. The parents ask the nurse what type of treatment to expect. What is the most appropriate response by the nurse? A. iron replacement and change of diet B. transfusion of packed red blood cells C. preparation for bone marrow transplant D. splenectomy and steroid therapy
A. iron replacement and change of diet
A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? A. knee-to-chest B. Fowler's C. Trendelenburg's D. prone
A. knee-to-chest
A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify: A. production of thick, sticky mucus. B. harsh, nonproductive cough. C. stridor. D. unilateral decrease in breath sounds.
A. production of thick, sticky mucus.
Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the health care provider (HCP) based on the interpretation that these findings may lead to which condition? A. respiratory arrest B. bronchial pneumonia C. intraventricular hemorrhage D. epiglottitis
A. respiratory arrest
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of risk for impaired skin integrity. Which intervention should be part of this clients care plan?
Avoiding using deodorant soap on the irradiated areas
A parent of a child with sickle cell anemia confides in the nurse that the parent feels guilty about letting the child run and play with the neighborhood children and that if the parent had been a better parent, the child wouldn't have suffered a sickle cell crisis. Which response would be most appropriate? A."The child is just fine now. Don't worry." B. "Tell me more about how you feel." C. "But you know that children with sickle cell anemia often have crises." D. "You shouldn't be so protective."
B. "Tell me more about how you feel."
A child has just returned to the pediatric unit following placement of a ventriculoperitoneal shunt for hydrocephalus. The child is placed in a supine position. What is the nurse's priorityintervention? A. Assess intake and output. B. Place the child on the side opposite the shunt. C. Teach on ventriculoperitoneal shut location. D. Administer oral pain medication as ordered.
B. Place the child on the side opposite the shunt.
The nurse is caring for a child with cystic fibrosis who is admitted to the floor with an upper respiratory tract infection. The child has labored breathing and a congested, nonproductive cough. What is the immediate priority for the nurse? A. infection B. airway C. nutrition D. family coping
B. airway
The primary healthcare provider prescribes betamethasone 43-year-old multigravid client at 32 weeks gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks gestation. The nurse explains that this drug is given for which reason?
To enhance the feet along maturity
A client with chronic cancer pain has been receiving opiates for four months. She rated the pain as an eight on a 10 point scale before starting the opioid medication. Following a thorough examination, there is no new evidence of increased disease, yet the pain is close to eight again. What is the most likely explanation for the increasing pain?
Tolerance to the opioid
A nurse at a community event is called to an unresponsive 3-year-old. The parent states the child was eating a hot dog. The nurse determines the child has an obstructed airway. After instructing an observer to call 911, what intervention should happen first? A. performing the Heimlich maneuver until the child starts choking or coughing B. opening the child's mouth and attempting to give 2 breaths C. delivering five back blows followed by five chest thrusts D. performing chest compressions with the heel of one hand 30 times
D. performing chest compressions with the heel of one hand 30 times
A client with cervical cancer and is undergoing internal radium implant therapy. A lead lined container in a pair of long forceps have been placed in the clients hospital room. What should the nurse tell the client about how these will be used? The forceps in the container will be used for:
Handling of the dislodged radiation source
What conditions with the nurse expect to find in a preterm neonate suffering from cold stress?
Hyperactivity and twitching
When evaluating a pregnant clients knowledge of symptoms to report immediately, which statement indicates to the nurse at the client understands the information given to her?
If I have blurred or double vision, I should call the clinic immediately
Well if you see a position with an NST pieces on a blank client at 38 weeks gestation, the nurse observes the fluid is very cloudy and thick. The nurse interpret this finding is indicating which of the following?
Intrauterine infection
What should the nurse include in the plan of care for a client with diabetes he was in labor?
Monitor blood glucose levels every hour
A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?
Monitor fetal heart tones
A nurse is caring for a newborn with transient tachypnea of the newborn. Which responses made by the newborns mother demonstrates that she understands the newborns condition? Select all that apply
-"Having a cesarean section increase the risk of transient tachypnea of my newborn." -" The healthcare provider will need chest x-rays to monitor my babies respiratory distress."
A client who is receiving chemotherapy express his concern at the thought of losing hair on their head. The nurses best response is:
"Your hair loss will be temporary. Would you like to tell me about your concerns?"
Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. -coughing -respiratory rate of 35 breaths/minute -heart rate of 95 beats/minute -restlessness -malaise -diaphoresis
-coughing -respiratory rate of 35 breaths/minute -restlessness -diaphoresis
Which client has the highest risk of ovarian cancer?
45-year-old woman who has never been pregnant
A nurse is conducting a cancer risk screening program. Which client is at greatest risk for skin cancer?
60 year old mountain biker
A multigravid client is receiving oxytocin augmentation. When the client cervix is dilated to 6 cm, her membranes rupture spontaneously with Laconian-staying amniotic fluid. Which actions should the nurse perform first?
Assess the fetal heart rate
At 6 cm dilation, a client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate?
Altered tissue perfusion related to effects of anesthesia
A client with an uncomplicated term pregnancy arrives at the labor and delivery unit in early labor saying that she thinks her water has broken. What is the nurse is best action?
Ask what time this happened and note the color, amount, and odor of the fluid
The 29-year-old multigravida c at 37 weeks gestation is being treated for severe preeclampsia and has magnesium sulfate in fusing at 3 g/hour. What is the priority intervention to maintain safety for this client?
Assess reflexes, clonus, visual disturbances, and headache
A client with diabetes Molite us gives birth to a 9 pound 10 ounce neonate at 38 weeks. What is the nurses priority action after the stabilization of the neonate?
Assess the neonate's blood glucose level
The nurse is assessing a to our old newborn. The nurse notes nasal flaring and acrocyanosis. Which of the following is the nurse is priority intervention?
Assess the newborns oxygen saturation
What should the nurse do first when admitting a toddler with croup? A. Monitor vital signs. B. Assess respiratory status. C. Ensure adequate fluid intake. D. Place a tracheostomy set at the bedside.
B. Assess respiratory status.
A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104° F (40° C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3 (16,000 X 109/L). What is priority for nursing intervention? A. infection B. airway obstruction C. difficulty breathing D. potential for aspiration
B. airway obstruction
A 4-year-old child with hydrocephalus is scheduled to have a ventroperitoneal shunt in the right side of the head. When developing the child's postoperative plan of care, the nurse should place the preschooler off of the operative site with the head of the bed in which position immediatelyafter surgery? A. high Fowler's B. semi-Fowler's C. flat D. Trendelenburg
C. flat
A client is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client?
Continuous fetal heart rate monitoring will be implemented
Which outcome is expected of a nursing referral to a cancer support group? The client can:
Cope with cancer.
An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the long has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused assessment for which symptom?
Dyspnea
A client had a right pneumonectomy Four lung cancer yesterday and now has dyspnea. What position in bed will be best for this client?
Head of bed elevated
The nurse is witnessing the client signature on the inform the surgical consent for an abdominal hysterectomy. The nurse should be certain the client understands that what will be the outcome of the surgery?
Infertility
Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will:
Maintain adequate nutrition through oral or parenteral feedings
The nurse on the previous night shift documented that the lungs have a client has lung cancer we are clear to auscultation in all fields. While doing the shift assessment, the dayshift nurse noticed decreased breath sounds, especially in the right lower lobe. Which action is the nurses best choice?
Notified the physician of the change in client status
The nurse is planning a presentation about ovarian cancer to a group of women. Which topic should receive priority attention in the lesson plan?
Ovarian cancer signs and symptoms are often vague until late in development
The nurse is caring for a woman who gave birth vaginally to a healthy 6 pound newborn after two hour labor at 37 weeks gestation period for which complication with a nurse assessed as a priority due to the increased risk in this client?
Postpartum hemorrhage
The nurse covers the Myelomeningocele of a neonate with the sterile dressing. Which statements direct the nurses action?
Preventing infection
A client is receiving chemo therapy to treat breast cancer. Which assessment findings indicate a chemo therapy-induced complication?
Serum potassium level of 2.6
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 client with suspected gastric cancer undergoes an endoscopy of the stomach. Which assessment made after the procedure would indicate the development of a potential complication?
The client experiences a sudden increase in temperature
A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow up?
The client reports a feeling of a lump in the throat.
Which client is at highest risk for colon rectal cancer?
The client who has been treated for Crohn's disease for 20 years
After amniotomy, Which client goal should take the highest priority?
The client will maintain adequate fetal tissue perfusion
A nurse obtained the antepartum history of a client who is six weeks pregnant. Which finding is a concern?
The clients consumption of 68 cans of beer on weekends
A client, who is one week postpartum, is concerned about the possibility of postpartum depression because she has a history of depression. Which, by the client would indicate that she understood the nurse is teaching about the postpartum. And her risk for postpartum depression?
"If I'm feeling guilty or not capable of caring for the baby and I'm not sleeping or eating well, I need to contact the office."
A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip? Select all that apply.
-positive Barlow test -asymmetrical leg skin folds
After a mastectomy for breast cancer, the nurse teaches the client how to avoid the development of lymphedema. The nurse should teach the client to:
Elevate the affected arm on a pillow
I'm at Sexting is recommended for a 68-year-old client diagnosed with breast cancer week ago. When approached about giving consent for the mastectomy, the client says, "what's the use in trying to get rid of the cancer? It will just come back! I can't handle another thing - having diabetes is enough. Besides, I'm getting old. It would be different if I were younger and had more energy." What should the nurse to?
Explore with client her feelings about her health problems and proposed surgery
Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer?
Female nurse with three years experience working in oncology
The family of an older adult with terminal cancer asks about having hospice services. What should the nurse tell the family? Hospice care:
Focuses on supportive care for the client and family.
When unit is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome. The neonate weighs 10 lbs. 4 oz. and is at 41 weeks gestation. What would be the priority problem for this neonate?
Impaired gas exchange
A client tells the nurse that her bra fits more snuggly at certain times of the month and she is concerned that she may have a side of breast cancer. The nurse should give the client which information about the situation?
It is normal for the breast to increase in size before menstruation begins
While performing a circle examination on a client in labor, a nurse his fingertips for your pulsating tissue. What is the most appropriate nursing intervention?
Leave the fingers in place and press the nurse call light
A woman tells the nurse, "T has been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer?
Light bleeding or watery vaginal discharge
After instructing a 20-year-old nulligravid About adverse effects of oral contraceptives, the nurse determines that further instructions needed when the client states which has an adverse effect?
Ovarian cancer
The membranes of a blank client in active labor back for spontaneously, revealing greenish any colored amniotic fluid. How does the nurse interpret this finding?
Passage of meconium by the fetus
I'm Delachal cord prolapse occurs after spontaneous rupture of membranes. What should the nurse do immediately?
Placethe client in a Trendelenburg position
The nurses in being a client about the past medical history. Which pre-existing condition may need the nurse to suspect that the client has colorectal cancer?
Polyps
The nurse caring for the labor and client performed a sterile vaginal exam. Exam results are dilated 10 cm, I faced 100%, and +2 station. What is the priority nursing intervention?
Prepare for birth of the neonate
16-year-old unmarried client visiting the prenatal clinic at 32 weeks gestation and currently weighing 144 pounds is being closely monitored for early signs of preeclampsia. The client is 5 feet, 2 inches tall and weighed 120 pounds before the pregnancy. Which factor would be most important to assess?
Protein in her urine
A 32-year-old blank return to the clinic for a routine prenatal visit at 36 weeks gestation. The assessments during this visit include: blood pressure 140/90, pulse 80, respiratory rate 16. What further information should the nurse obtained to determine if this client is becoming preeclamptic?
Protein in her urine
An 18-year-old pregnant client tells the nurse that she is concerned that she may not be able to take care of herself during her pregnancy. She states that she is not sure what prenatal care is available, or if she should access it. The nurse should recognize that the client:
Should be referred to community resources available for pregnant women
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou Test, the Physician diagnosis stage for ovarian cancer. The nurse expect to prepare the client for which initial treatment?
Surgical procedure
When assessing a child with bronchiolitis, which finding does the nurse expect? A. clubbed fingers B. barrel chest C. barking cough and stridor D. productive cough
D. productive cough
Which statement indicates that the client understands the need for routine screening to detect colorectal cancer?
"I need to have a colonoscopy at age45 then every 10 years until age 75."
The client with brown hair is concerned about losing hair as a result of chemotherapy. What should the nurse tell the client?
"The hair loss is temporary. "
A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply. -bulging anterior fontanel -fever -nuchal rigidity -petechiae -irritability -photophobia
-fever -nuchal rigidity -irritability -photophobia
The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which signs and symptoms? Select all that apply. -irritability -headache -mood swings -bulging fontanel -emesis
-irritability -bulging fontanel -emesis
A nurse is taking a history from the parents of a 11-year-old child admitted with Reye's syndrome. Which illness should the nurse expect the parents to report their child having the previous week? A. chickenpox B. bacterial meningitis C. strep throat D. Lyme disease
A. chickenpox
A client who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? Select all that apply.
-Chromosomal defects -Neural tube defects -Sex of the fetus
The nurse is assessing in our old newborn. Which observations with the nurse know as being abnormal? Select all that apply.
-Expiratory grunting -Temperature of 97.4°F -nasal flaring
A nurse is caring for a newborn exposed to drugs while in utero. Which behaviors will the nurse expects a newborn to exhibit? Select all that apply.
-Tachypnea with excessive secretions -Sensitive gag reflex -hyper activity and increased muscle tone
The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks gestation with severe preeclampsia. What are desired outcomes for us therapy? Select all that apply.
-Temperature 98°F, pulse 72, respiratory rate 14 -Deep tendon reflexes 2+ -Magnesium level 5.6
A nurse is completing a prenatal assessment on a woman who is 28 weeks pregnant with gestational hypertension. Which finding should be reported to the primary care provider?.
-dull headache -Blurred vision -1+ urine protein
A nurse is reviewing an infant's progress notes.Progress notes10/15/160800Four-month-old infant admitted last evening. Wt: 4.95 kg. (10%) Ht: 66 cm (95%), Frequent episodes of bradycardia, tachypnea. Breastfeeding every 4 hours for 30 minutes on each side.What notations would lead the nurse to suspect that this infant has a ventricular septal defect? Select all that apply. -tachypnea -plots at 95th percentile for height on growth chart -plots at the 10th percentile for weight on growth chart -bradycardia -increased length of time to finish breastfeeding
-tachypnea -plots at the 10th percentile for weight on growth chart increased length of time to finish breastfeeding
A client in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and vomiting all the time. I can't even keep down water." This client should be evaluated for what condition?
Hyperemesis gravidarum
The nurse should be especially alert for what problem and caring for terminate, who weighed 10 pounds at birth, one hour after a vaginal birth?
Hypoglycemia
The nurse is admitting a primigravid client at 37 weeks gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most important first client?
A darkened private room as close to the nurses station as possible
The nurse assesses a child with fever, sensitivity to light, and a red rash on the back. How will the nurse assess for Kernig's sign? A. Have the child lie supine with flexed knees, then ask the child to extend the knees. B. Have the child sit, and tap the child's face over the facial nerve area. C. Place the child in the supine position, and inflate a blood pressure cuff on the arm. D. Have the child stand, and ask the child to flex the neck by bringing the chin to the chest.
A. Have the child lie supine with flexed knees, then ask the child to extend the knees.
Which outcome with the nurse identify as a priority to achieve when developing a plan of care for a primigravid client at 38 weeks gestation was hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?
Absence of any seizure activity during the first 48 hours
The third stage of labor ends
After the birth of the placenta
The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommends to women age 50 and older?
Annual mammogram
A nurse is assisting in developing a teaching plan for a client who's about to enter the third trimester of pregnancy. The teaching plan should know that which symptom should be reported immediately?
Blurred vision
The client has given birth to a pre-terminate. The client tells the nurse that she wants to breast-feed her neonate. The nurse should explain to the mother that:
Breast milk contains antibodies that help protect her neonate
The nurse is providing teaching to the parents of a young child with a urinary tract infection. The nurse's goal is to help the parents understand their role in the treatment of the infection. Which statement by the parents lets the nurse know that the teaching has been successful? A. "We can treat the infection by increasing oral fluid intake." B. "We need to encourage cranberry juice to treat the infection." C. "We need to administer the oral antibiotics as prescribed." D. "We need to come to the emergency department for IV fluids."
C. "We need to administer the oral antibiotics as prescribed."
A client in active labor asked the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse?
Changes in your blood pressure can affect the fetus
When caring for the neonate weighing 4564g (10.lb) born vaginally to a woman with diabetes, the nurse should assess the neonate for fracture of which area?
Clavicle
A 30-year-old client whose mother died of breast cancer at age 44 and his sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, The nurse should suggest that the client ask the physician about which topic?
Genetic counseling
The client gives birth to a neonate who is giving a score of nine at five minutes on the Apgar rating system. How does the nurse interpret the new needs physical condition?
Good
Journey initial assessment of labor and client, the nurse notes the following: blood pressure 160/110, pulse 88, Respiratory rate 22, reflexes +3 Dash +4 with to be clonus. Urine specimen reveals +3 protein, negative sugar in key tones. Based on these findings, a nurse should expect the client to have which complaints?
Headache, blurred vision, and facial and extremity swelling
A client with suspected cervical cancer has a colposcopy with conversation. What information should the nurse give the client about her menstrual period after the surgery?
Her next two or three periods may be heavier and more prolonged than usual
The nurse is reviewing a clients prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth?
History of postpartum hemorrhage
A pregnant client arrives in the emergency department in states, "my baby is coming." The nurse is a portion of the umbilical cord protruding from the vagina. What should the nurse do first?
Hold pressure on the fetal head
The client underboss and amniotomy. Afterword, the nurse to text large variable decelerations in the fetal heart rate on the external electronica fetal monitor. These findings signify:
Umbilical cord prolapse
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? A. Institute droplet precautions. B. Obtain the child's vital signs. C. Ask the parent about medication allergies. D. Inquire about the health of siblings at home.
A. Institute droplet precautions.
A parent brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. -Limit fluids for the next few days to decrease the frequency of urination. -Assess the parent's understanding of UTI and its causes. -Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. -Provide instructions only to the parent, not the child. -Tell the parent to have the child wipe the back to the front after voiding and defecation.
-Assess the parent's understanding of UTI and its causes. -Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish.
A client is receiving monthly doses of chemo therapy for treatment of stage III Colon cancer. Which laboratory results to the nurse reports be oncologist before the next dose of chemotherapy is administered. Select all that apply.
-Platelet count of 40,000/mm3 -White blood cell count of 2300/mm3 -temperature of 101.2°F
Parents bring a 10-month-old boy with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are appropriate? Select all that apply. -Weigh the child. -Listen to bowel sounds. -Palpate the posterior fontanel. -Obtain vital signs. -Assess pitch and quality of the child's cry.
-Weigh the child. -Listen to bowel sounds. -Obtain vital signs. -Assess pitch and quality of the child's cry.
The nurse is educating a group of parents about respiratory disorders in young children. One of the mothers tells the nurse that she has noticed her child's nostrils flaring when a child has a respiratory infection. The mother asked the nurse if she should be concerned. What is the most appropriate response by the nurse? A. "nasal flaring occurs when a child has to work hard to breathe." B. "A child exhibiting nasal flaring should be seen by a physician." C. "When a child is breathing deeply, nasal flaring will occur." D. "Nasal flaring is a common respiratory symptoms in children and adults."
A. Nasal flaring occurs when a child has to work hard to breathe.
A client with iron deficiency anemia was prescribed ferrous sulfate. Which statement by the caregiver would indicate a need for further instruction on proper administration? A. "I mix the medication in milk to make it taste better." B. "I give the medication in the morning before breakfast." C. "I give the ferrous sulfate at a different time than my child's other medications." D. "I encourage my child to drink lots of fluids."
A. "I mix the medication in milk to make it taste better."
The nurse is teaching a parent and child with iron deficiency anemia. The parent asks the nurse why the ferrous sulfate needs to be mixed with citrus juice. What is the best response by the nurse? A. "The vitamin C in the citrus juice helps with iron absorption." B. "Having food and juice in the stomach helps with iron absorption." C. "The citrus juice counteracts the unpleasant taste of the iron." D. "The child will take the iron mixed with juice better than water."
A. "The vitamin C in the citrus juice helps with iron absorption."
A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? A. Encourage a high-calorie, high-protein diet. B. Restrict fluids to 1,500 ml per day. C. Limit salt intake to 2 g per day. D. Encourage foods high in vitamin B.
A. Encourage a high-calorie, high-protein diet.
A nurse is caring for an infant being treated for an upper respiratory infection. The physician would like to order a series of x-rays for the infant who has been in a foster home for four months. How should the nurse obtained consent? A. Obtain consent from the foster parents B. Call child protective services C. Contact the child's biological parent D. Contact the units director of nursing
A. Obtain consent from the foster parents
The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment? A. a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling B. a 3-year-old with a fever of 100° F (37.8° C), a barky cough, and mild intercostal retractions C. a 4-year-old with a fever of 101° F (38.3° C), a hoarse cough, inspiratory stridor, and restlessness D. a 13-year-old with a fever of 104° F (40° C), chills, and a cough with thick yellow secretions
A. a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling
A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to: A. combat inflammation. B. prevent infection. C. prevent platelet aggregation. D. promote diuresis.
A. combat inflammation.
A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse assesses the child and finds a hoarse voice, inspiratory stridor, fever, and a barking cough. What would the nurse anticipate for admission orders? A. cool mist humidification B. expectorant cough syrup C. antibiotics D. inhaled bronchodilator
A. cool mist humidification
An adolescent with well-controlled type 1 diabetes has assumed complete management of the disease and wants to participate in gymnastics after school. To ensure safe participation, the nurse should instruct the client to adjust the therapeutic regimen by: A. eating a snack before each gymnastics practice. B. measuring urine glucose level before each gymnastics practice. C. measuring blood glucose level after each gymnastics practice. D. increasing morning dosage of intermediate-acting insulin.
A. eating a snack before each gymnastics practice.
The nurse assessment of a 6-month-old infant brought to the outpatient clinic reveals a respiratory rate of 52 breaths/min, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which action would be the most appropriate? A. Administer a nebulizer treatment B. Send to the infant for a chest radiograph C. Refer the infant to the emergency department D. Provide teaching about cold care to the mother
C. Refer the infant to the emergency department
A client is being discharged after abdominal surgery and colostomy formation to treat: cancer. Which nursing action is most likely to promote continuity of care?
Asking the physician to write an order for home skilled nursing assessments and interventions
The nurse is teaching a group of parents about the risk of airway obstruction in young children. What information is most appropriate for the nurse to share regarding the risk of airway obstruction? A. "Sleeing with a blanket is safe for the child after the child can roll over on one's own." B. "A small airway makes it easier for for an objects to cause obstruction." C. "A flat diaphragm makes it easier to expel objects obstructing the airway." D. "After the child start school the risk for the child getting an obstruction decreases."
B. " A small airway makes it easier for foreign objects to cause obstruction."
A nurse is teaching the parents of an infant with cystic fibrosis about chest percussion therapy. Which statement by the nurse is most accurate in explaining the rationale for using chest percussion on infants with cystic fibrosis? A. "Chest percussion is used as an adjunct to nebulizer treatments." B. "Chest percussion helps clear secretions out of the lungs." C. "Chest percussion is needed everyday to prevent infection." D. "Chest percussion is needed only when the child is ill."
B. "Chest percussion helps clear secretions out of the lungs."
A toddler with croup is given a racemic epinephrine treatment because of increasing respiratory distress. Which finding indicates that the treatment has been effective? A. Color is normal. B. Retractions are less severe. C. Heart rate is 100 bpm. D. Pulse oximeter reads 90.
B. Retractions are less severe.
A child with cystic fibrosis does not like taking a pancreatic enzyme supplement with meals and snacks. The parent does not like to force the child to take the supplement. What is the mostimportant reason for the child to take the pancreatic enzyme supplement with meals and snacks? A. The child will become dehydrated if the supplement is not taken with meals and snacks. B. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins. C. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear. D. The child will experience severe diarrhea if the supplement is not taken as prescribed.
B. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins.
The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. What information should the nurse give to the clients? A. A disease carrier also has the disease. B. Two parents who are carriers may produce a child who has the disease. C. A disease carrier and an affected person will never have children with the disease. D. A disease carrier and an affected person will have a child with the disease.
B. Two parents who are carriers may produce a child who has the disease.
A 7-year-old has been diagnosed with bacterial meningitis. Who should receive chemoprophylaxis? A. all children at the school B. all household contacts and close contacts C. the entire community D. household contacts only
B. all household contacts and close contacts
When teaching a parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include? A. burning or pain with urination B. complaints of a stiff neck C. fever disappearing for longer than 24 hours, then returning D. history of febrile seizures
B. complaints of a stiff neck
A child is admitted to the emergency department with an acute asthma attack. Which early assessment finding does the nurse expect? A. decreased respiratory rate B. expiratory wheezing C. inspiratory stridor D. cyanosis
B. expiratory wheezing
The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which factor? A. chronic anemia B. peripheral hypoxia C. delayed physical growth D. destruction of bone marrow
B. peripheral hypoxia
A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic work up. The nurse reviewed the clients history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?
Bleeding disorder
A mother asks the nurse how to handle her 4-year-old child, who recently has had episodes of urinary incontinence after being completely toilet-trained. What is the best response by the nurse? A. "What have you done to prevent this from happening?" B. "Have your other children experienced this same thing?" C. "Has your child experienced any recent changes in routine?" D. "Is your child angry with you about something?"
C. "Has your child experienced any recent changes in routine?"
The nurse at the clinic is assessing a toddler and notices retractions while the child is breathing. The parents state that they began to notice the retractions a few days ago and wondered if it was significant. What is the best response by the nurse? A. "Retractions occur normally when children are very active." B. "This is very serious; you should have brought your child in sooner." C. "Your child is having difficulty breathing and we need to determine why." D. "This is an indication that your child has a respiratory infection."
C. "Your child is having difficulty breathing and we need to determine why."
An emergency department nurse is caring for a child diagnosed with moderately severe croup. The nebulizer treatment of choice for a child with moderate to severe croup is: A. albuterol. B. budesonide. C. epinephrine. D. ipratropium bromide.
C. epinephrine.
An overweight adolescent has been diagnosed with type 2 diabetes. What should the nurse do to increase the client's self-efficacy to manage the disease? A. Provide the client with a written daily food and exercise plan. B. Discuss eliminating junk food in the home with the parents. C. Arrange for the school nurse to weigh the child weekly. D. Utilize a peer with type 2 diabetes to role model lifestyle changes.
D. Utilize a peer with type 2 diabetes to role model lifestyle changes.
A nurse working in the triage area of an emergency department sees several pediatric clients arrive simultaneously. Which client should be treated first? A. a crying 4-year-old child with a laceration on the scalp B. a 3-year-old child with a barking cough and flushed appearance C. a 3-year-old child with Down syndrome who's pale and asleep D. a 2-year-old child with stridorous breath sounds, sitting up and drooling
D. a 2-year-old child with stridorous breath sounds, sitting up and drooling
A 2-year-old client is brought to the emergency department with suspected croup. The client appears frightened and cries as the nurse approaches him. The nurse needs to assess the client's breath sounds. The best way to approach the client is to" A. expose the client's chest quickly and auscultate breath sounds as quickly and efficiently as possible. B. ask the caregiver to wait briefly outside until the assessment is over. C. tell the client the nurse is going to listen to the chest with the stethoscope. D. allow the client to handle the stethoscope before the nurse listens to the client's lungs.
D. allow the client to handle the stethoscope before the nurse listens to the client's lungs.
The nurse is assessing breath sounds of a child admitted to the unit. Based on the following progress notes, which respiratory illness would the nurse suspect?Progress notes10/152030Seven-year-old child admitted from ER. Oxygen via mask at 4 L/min. Frequent, tight cough. A/Ox3. Shortness of breath noted while talking to mom. HEENT normal. Lungs with wheezing in bases. Heart RRR, no murmur. Abdomen soft, flat. Active bowel sounds. Moving all extremities well. A. pneumonia B. croup C. pulmonary edema D. asthma
D. asthma
A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone? A. autonomy B. initiative C. industry D. identity
D. identity
A nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider? A. inappropriate parental concern for the degree of injury B. absence of parents to question about the injury C. inappropriate response of the child to the injury D. incompatibility between the child's history and the injury
D. incompatibility between the child's history and the injury
The nurse is teaching a client who is receiving chemotherapy and the family how to manage possible nausea and vomiting at home. What information should the nurse include in the teaching plan?
Eating small frequent meals
Which strategy would be most effective in improving trans cultural communications with oncology clients and their families?
Establish a rapport and listen to their concerns.
After a lobectomy for lung cancer, the nurse instructed the client to perform deep breathing exercises. What is the expected outcome of these exercises?
Expand the alveoli and increase long surfaces available for ventilation
A nurse is the average age of 47 following American Cancer Society Guidelines, the nurse she recommends that the women:
Have a mammogram annually
A client, age 42, visits the gynecologist. After examining the client, the healthcare provider suspects cervical cancer. What will be most important for the nurse to include in assessing the clients health history?
History of human papilloma virus infection.
The nurse should teach clients about which potential risk factor for the development of colon cancer?
History of inflammatory bowel disease
A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?
Laxative
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
A client ask the nurse with PSA is. The nurse should reply that it stands for:
Prostate-specific antigen, which is used to screen for prostate cancer
Which action is most important when the nurses planning pain management for a client after a lobectomy for lung cancer?
Reassessing the client after administering pain medication
A client with a modified radical mastectomy has been discharged. The client has been very reluctant to discuss the surgery or her situation. The nurse making assignments should delegate the clients care to the:
Same nurse who has cared for her the past three days, for continuity of care.
The client with stage to ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomt, appendectomy, and Lymphadenectomy. During the second postoperative day, which assessment finding requires immediate intervention?
Shallow breathing and increasing lethargy
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes at the drainage system is functioning correctly when the nurse notes title movements or fluctuations in which compartment of the system as the client breathes?
Water-seal chamber