SAUNDERS TEST BANK

Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided?

"Administer the antibiotics until they are gone."

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response should the nurse make?

"Antibiotics are not indicated unless a bacterial infection is present"

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response?

"At this age, the child is developing his own personality."

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?

"Did the child have sore throat or fever within the last 2 months?"

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

"Do you plan to have any other children?'

Which question should the nurse asks the parents of a child suspected of having glomerulonephritis?

"Has the child had a sore throat or throat infection in the last few weeks?

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents asks the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response?

"Have the child perform simple isometric exercises during this time."

The nurse has provided home care instructions to the parents of a child who is being after cardiac surgery. Which statement made by the parents indicates a need for further instruction?

"I can apply lotion or powder to the incision if it is itchy"

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?

"I can use lotion or powder around the cast edges to relieve itching."

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

"I drink hot chocolate before bedtime."

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery."

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further teaching?

"I need to lie flat on my back to perform the procedure."

The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?

"I noticed his urine was the color of cola lately"

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?

"I should apply lotion under the brace to prevent skin breakdown."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I should avoid exercise because because of the negative effects on insulin production."

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

The nurse is providing instructions to a client and the family regarding home care right after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?

"I should sleep on my left side."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water."

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction?

"I will ask the nurse to attend to my infant if I am napping and my husband is not here."

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

"I will call the nursing supervisor to seek assistance regarding your request."

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is need about administration of the eye medication?

"I will flush the eyes after instilling the ointment."

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction?

"I will let him decide when to return to his play activities"

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?

"I will maintain strict bed rest throughout the remainder of the pregnancy."

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy."

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction?

"If my child vomits after medication administration. I will repeat the dose"

The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother indicates a need for further teaching?

"It is okay to share towels and washcloths."

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

"It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

"Lesions most often are located on the arms and chest."

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond?

"Living in a prison can predispose a person to different health conditions."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity."

The nurse prepares to administer Phytonadione (Vitamin K) injection to a newborn, and the mother asks the nurse why the infant needs the injection. What best response should the nurse provide?

"Newborns are deficient in Vitamin K, and this injection prevents your newborn from bleeding."

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response?

"Please share with me more about your concerns."

The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by. member of the nursing staff indicates a need for information?

"The child does not experience pain at the primary tumor site

The clinic nurse is providing instructions to a parent of a child with cystic fibrous regarding the immunization schedule for the child. Which statement should the nurse make to the parent?

"The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination"

A pregnant client in the first trimester calls the nurse at the health care clinic and reports that she has noticed a thin, colorless vaginal discharge. The nurse should make which statement to the client?

"The vaginal discharge may be bothersome but is a normal occurrence."

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

"Use of an incentive spirometer will help prevent pneumonia."

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

A 2-year-old child is treated in the emergency department for a burn on the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home?

"We will be sure not to leave liquids unattended."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

"What can I do for you?"

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth."

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The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply

-"I should wear a bra that provides support." -"Drinking alcohol can affect my milk supply." -"The use of caffeine can decrease my milk supply." -"I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

-"It connects the umbilical vein to the inferior vena cava."

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply

-"The ductus arteriousus allows blood to bypass the fetal lungs." -"One vein carries oxygenated blood from the placenta to the fetus." -"Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?

-A client requiring abdominal wound irrigations and dressing changes every 3 hours

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply

-A delay in growth may occur after a burn injury -An immature immune system presents an increased risk of infection for infants and young children -Infants and young children are at an increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply

-A primigravida with abruptio placenta -A gravida 2 who has just been diagnosed with dead fetus syndrome -A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

The nurse is performing an assessment on a 10-year old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply

-Abdominal pain -Painless, firm, and movable adenopathy in the cervical area

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply

-Administration of subcutaneous heparin postdelivery as prescribed. -An overbed lift may be necessary if the client requires a cesarean section. -Thromboembolism stockings or sequential compression devices may be prescribed.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply

-Age 54 years -Body mass index of 28 -Previous difficulty with fertility

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply

-Allows for fetal movement -Surrounds, cushions, and protects the fetus -Maintains the body temperature of the fetus -Can be used to measure fetal kidney function

Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?

-Apply the lotion to cool, dry skin at least 30 minutes after bathing.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

-Auscultating lung sounds -Obtaining the client's temperature -Obtaining information about the client's respirations

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply

-Ballottement -Chadwick's sign -Uterine enlargement -Positive pregnancy test

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? select all that apply

-Bright red vaginal bleeding -Soft, relaxed, nontender uterus -Fundal height may be greater than expected for gestational age

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.

-Broth -Coffee -Gelatin

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.

-Contact the surgeon -Instruct the client to remain quiet -Prepare the client for wound closure -Document the findings and actions taken

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply

-Cyanosis -Tachypnea -Retractions Audible grunts

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply

-Decline in visual acuity -Increased susceptibility to urinary tract infections -Increased incidence of awakening after sleep onset

The nurse is conducting staff in-service training on Von Willebrand's disease. Which should the nurse include as characteristics of Von Willebrand's disease? Select all that apply

-Easy bruising occurs -Gum bleeding occurs -It is a hereditary bleeding disorder -Treatment and care are similar to that for hemophilia -The disorder causes platelets to adhere to damaged epithelium

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply

-Encourage expression of feelings, concerns, and fears -Touch and hold the client's or family member's hand if appropriate -Be honest and let the client and family know they will not be abandoned by the nurse

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization . Which nursing intervention should be implemented to alleviate the child's fears?

-Encourage the child's parents to stay with the child

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply

-Flushing -Depressed respirations -Extreme muscle weakness

An adolescent client with type I Diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

-Fruity breath odor and decreasing level of consciousness

The nurse should implement which interventions for a child older than 2 years with type 1 Diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L) Select all that apply

-Give the child a teaspoon of honey -Prepare to administer glucagon subcutaneously if unconsciousness occurs

A client arrives at the birthing center in active labor. After examination, it is determined that her membranes are still in tact and she is still at -2 station. The primary health provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply

-Increased efficiency of contractions -The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

-Inhalation of bacterial spores -Through a cut or abrasion in the skin -Ingestion of contaminated undercooked meat

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply

-Irritability -Constant crying -Difficult to comfort

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply

-It is the way the baby gets food and oxygen -It provides an exchange of nutrients and waste products between the mother and the developing fetus

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply

-Looking at old snapshots of family -Participating in a senior citizens program -Visiting the spouse's grave once a month -Decorating a wall with the spouse's pictures and awards received

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

-Margarine -Cream cheese -Luncheon meats

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply

-Monitor skin temperature closely -Reposition the newborn every 2 hours -Cover the newborn's eyes with eye shields or patches

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply.

-Moral development progresses in relationship to cognitive development -A person's ability to make moral judgments develops over a period of time -The theory provides a framework of understanding how individuals determine a moral code to guide their behavior -In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply

-Move beds away from windows -Close window shades and curtains -Place blankets over clients who are confined to bed

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

-Nausea -Confusion -Tachycardia -Lightheadedness

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply

-Obtain an intravenous (IV) infusion pump -Monitor urine output during administration -Monitor the IV site for signs of infiltration or phlebitis -Ensure that the medication is diluted in the appropriate volume of fluid -Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply

-Pallor -Edema -Anorexia -Proteinuria

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.

-Peas -Nuts -Cauliflower

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply

-Place the infant in a private room -Wear mask, gown, and gloves when in contact with the infant -Ensure that nurses caring for the infant with RSV do not care for other high-risk children

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.

-Platelets 35,000 mm3 (35 × 109/L) -Sodium 150 mEq/L (150 mmol/L) -Segmented neutrophils 40% (0.40) -White blood cells, 3000 mm3 (3.0 × 109/L)

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply

-Pregnancy needs to avoided for 1 to 3 months -The vaccine is administered by the subcutaneous route -Exposure to immunosuppressed individuals needs to be avoided -A hypersensitivity reaction can occur if the client has an allergy to eggs

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply.

-Prolonged QT interval -Prolonged ST segment

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that that apply

-Provide a soft diet -Administer ibuprofen for fever every 4 hours as prescribed and as needed -Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy

Which interventions are appropriate for the care of an infant? Select all that apply

-Provide swaddling -Hang mobiles with black and white contrast designs -Caress the infant while bathing or during diaper changes

Which interventions should the nurse include when creating a plan of care for a child with hepatitis? Select all that apply

-Providing low-fat, well-balanced diet -Teaching the child effective hand-washing techniques -Instructing the parents to avoid administering medications unless prescribed

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.

-Raisins -Potatoes -Cantaloupe -Strawberries

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply

-Reduce exposure to environmental organisms -Use strict aseptic technique for all procedures -Ensure that anyone entering the child's room wears a mask

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply

-Respirations of 10 breaths per minute -Uterine output of 20mL in an hour

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.

-Respirations that are increased in rate -Respirations that are abnormally deep

The nurse is reviewing the health care provider's prescriptions for a child with sickle cell anemia who is admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply

-Restrict fluid intake -Give meperidine, 25mg intravenously, every 4 hours for pain

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual 1mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply.

-Right-click on the entry and modify it to reflect the correct information -Document the correct information and end with the nurse's signature and title -Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg -Document in a nurse's note in the client's record detailing the corrected information.

A parent of a 3-year-old tells the clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply

-Set limits on the child's behavior -Provide a simple explanation of why the behavior is unacceptable

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply.

-Sleep problems -Bipolar disorder -Aggressive behavior -Attention-deficit hyperactivity disorder (ADHD)

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

-Tall peaked T waves -Widened QRS complexes

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

-The acuity level of the clients -Client needs and workers' needs and abilities

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply

-The cervix is dilated completely -The Ferguson reflex is initiated from perineal pressure

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply

-The child had a previous anaphylactic reaction to the vaccine -The child has a disorder that caused a severely deficient immune system

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply

-The client has a history of intravenous drug use. -The client has history of sexually transmitted infections.

Which identifies accurate nursing documentation notation(s)? Select all that apply.

-The client slept through the night -Abdominal wound dressing is dry and intact without drainage -The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

-The client who is taking diuretics

The nurse is creating a plan of care for child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply

-Time the seizure -Stay with the child -Move furniture away from the child

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

-U waves -Inverted T waves -Depressed ST segment

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply

-Uterine hyperstimulation -Late decelerations of the fetal heart rate

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply.

-Warfarin -Glimepiride -Amlodipine

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply

-Wear a supportive bra -Rest during the acute phase -Maintain a fluid intake of at least 3000ml/day -Continue to breast-feed if the breast are not too sore

A prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters (mL) to administer the correct dose? Fill in the blank.

0.8 mL

The nurse is caring for a client following a craniotomy, in which a large cancerous tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the figure.

1-Bed elevated 30-45 degrees to promote venous drainage from the head.

A prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-milliliters (mL) ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place.

1.3 mL

A prescription reads Levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank.

1.5 Tablets

A prescription reads to infuse 1 unit of packed red blood cells over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

10 drops per minute

A prescription reads 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters (mL) per hour will be administered to the client? Fill in the blank.

125 mL/hr

A prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters (mL) of potassium chloride to administer the correct dose of medication? Fill in the blank.

15 mL

A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL (5.4 mmol/L)

A prescription reads heparin sodium, 1300 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number.

16 mL/hr

A prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.

2 Capsules

A prescription reads clindamycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters (mL) of the medication to administer the correct dose? Fill in the blank.

2 mL

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L)

A prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 drops per minute

Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.

25 Drops per minute

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?

3.2 mEq/L (3.2 mmol/L)

A prescription reads 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

31 drops per minute

Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

33 drops per minute

A prescription reads 1000 mL D5W to infuse at a rate of 125 mL/hr. The nurse determines that it will take how many hours for 1 L to infuse? Fill in the blank.

8 Hours

A prescription reads regular insulin, 8 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 8 units/hr? Fill in the blank.

8 mL/Hr

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

A blowing or swooshing noise

The nursing student is presenting a clinical conference and discusses the cause of B-Thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

A child of Mediterranean decent

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

A client who requires urine specimen collections

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with an ileostomy

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

A client with asthma who requested a breathing treatment during the previous shift

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

A nonstress test is performed on a client who is pregnant, and the results of the test indicate non-reactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

A normal test result

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

A physical obstruction to the transmission of sound waves

A child is receiving a series of hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of severe allergy to which substance?

A previous dose of hepatitis B vaccine or component

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up?

A reddish-purple mark on the neck

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which?

A wagon

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse?

A woman who has advanced Parkinson's disease

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

Abnormal palmer creases

The nurse caring for a refugee considers which health care need a priority for this client?

Access to mental health care services

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?

Activate the emergency response plan specific to the facility

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm

The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

Activity intolerance

The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Adequacy of capillary filling

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes late decelerations on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?

Administer oxygen, 8 to 10 L/minute, by face mask

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Administer oxygen, 8 to 10L/minute, via face mask

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid iron supplement. Which instruction should the nurse tell the parents?

Administer the iron through a straw

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?

After a shower or bath

The mother of a 3-year-old child is concerned because her child still is insisting on a bottle at nap time and bed time. Which is the most appropriate suggestion to the mother?

Allow the bottle if it contains water.

A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?

Allow the client to interact with others in his or her same age group

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure?

Allow the newborn infant to signal a need

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client?

Allowing the client to choose social activites

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted , would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats per minute

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?

Anti-streptolysin O titer

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent?

Apply a cold pack to the injection site.

A topical corticosteroid is prescribed by the health care provider for a child with contact dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

Apply a thin layer of cream and rub it into the area thoroughly

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care

The nurse is admitting a pregnant a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electric fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

Assess the patency of the airway

The nurse is reviewing the record of a client in the labor room and notes that the primary health care provider has documented that the fetal presenting part is at the +1 station. This documented findings indicate that the fetal presenting part is located at which area?

At +1 station, the fetal presenting part is 1cm below the ischial spine

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

Attempt to arouse the client

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?

Bacteriuria

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?

Bed rest with elevation of the affected extremity

The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure?

Bed rest with head elevation no greater than 30 degrees

Rh(D) immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?

Being affected by Rh incompatibility

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?

Betamethasone

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment?

Blood pressure

A 4-year old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis?

Bone marrow biopsy showing blast cells

Which car safety device should be used for a child who is 8 years old and is 4 feet tall?

Booster seat

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of ICP?

Bradycardia

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Bright red blood and mucus in the stools

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Bring the infant to the clinic

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?

Call the Poison Control Center

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

Call the nursing supervisor

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?

Call the nursing supervisor and report the occurrence

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

A child is placed in a skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?

Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied

A pediatrician prescribes an intravenous (IV) solution of 5% Dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

Choking with feedings

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?

Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first?

Complaints of pain associated with numbness and tingling in both feet

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

Confront the AP to encourage verbalization of feelings regarding the change.

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?

Conjunctival hyperemia

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?

Connect the resuscitation bag to the oxygen outlet

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action?

Contact the electrical maintenance department for assistance

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?

Contact the nursing supervisor

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?

Contact the obstetrician (OB) and inform him or her of this finding

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother?

Continue to breast-feed every 2 to 4 hours

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?

Cover the bladder with nonadhering plastic wrap

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for the child?

Crayons and a coloring book

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?

Cream of wheat, blueberries, coffee

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?

Crusting

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client?

Custard

A parent brings a 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant?

DTaP, Hib, IPV, pneumoccal vaccine (PCV), rotavirus vaccine (RV)

A 10-year old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing

A child with B-Thalassemia is receiving a long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusion. Which medication should the nurse anticipate being prescribed?

Deferoxamine

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placenta is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?

Delivery of the fetus

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?

Determine whether there are medication duplications

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been between 120 and 122 beats per minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. on the basis of this finding, which nursing action is most apprpriate?

Document the finding

The nurse assesses the vitual signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate?

Document the findings

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. which nursing action is most appropriate?

Document the findings

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electric fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

A school-age child with type 1 Diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do?

Eat a small box of raisins or drink a cup of orange juice before practice

The nurse is caring for a client with a severe burn who is scheduled for an autograph to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?

Elevate and Immobilize the grafted extremity

A mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids

The mother of an 8-year old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

Encourage the child to lie on the right side

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands?

Every 30 minutes

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura.

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

Failure to pass meconium stool in the first 24 hours after birth

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)?

Fetal heart rate of 180 beats per minute

Which assessment finding after an amniotomy should be conducted first?

Fetal heart rate pattern

The mother of a 3-year old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?

Fine grayish red lines

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?

Fluid overload

The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

Foul smelling ribbon-like stools

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Frequent swallowing

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

G=2, T=1, P=0, A=0, L=1

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?

Generalized edema

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed?

Glipizide

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before going into surgery.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

Hemoglobin, 8.0 g/dL (80 mmol/L)

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa.

Hemorrhage

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion ?

High-Fowler's

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

Hyperactive bowel sounds

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assess the client for which sign of preeclampsia?

Hypertension

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action?

Increase hydration by encouraging oral fluids

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age related body changes, could place the client at risk for which complication with medication therapy?

Increased risk for digoxin toxicity

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Increasing restlessness

A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother?

Inform the child of bedtime a few minutes before it is time for bed.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton's Hicks contractions. On the basis of this finding which nursing action is appropriate?

Inform the client that these contractions are common and may occur throughout the pregnancy

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 x 10/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care?

Initiate bleeding precautions

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

Integumentary output

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?

Intratracheal

A 10-year old with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?

Intravenous infusion of factor VIII

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room

A pregnant client reports to the health care clinic, complaining of loss of appetite, weigh loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium Tuberculosis. Which instruction should the nurse include in the client's teaching plan?

Isoniazid plus Rifampin will be required for 9 months

A mother brings her 2-week old infant to the clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation?

It is negative

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using the Nagele's Rule, which expected date of delivery should the nurse document in the client's chart?

July 26th, 2021

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

Leaving the rate of the heparin infusion as is

An infant has just to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

Left lateral position

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?

Legumes

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action?

Let the mother hold the child and direct the cool mist over the child's face

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition?

Limited range of motion in the affected hip

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Lying in bed on the unaffected side

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?

Maintaining safety because of low blood glucose levels

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

Malnutrition

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus until it is firm

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Massage the fundus until it is firm

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis

A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

Metabolic Alkalosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Metabolic alkalosis

The nurse is administering a cleansing enema to a client with a fecal impaction. before administering the enema, the nurse should place the client in which position?

Modified Left Lateral Recumbent Position

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

Monitor the newborn's response to feedings and weight gain pattern

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a private room

An opiod analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur?

Naloxone

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and should contact the pediatrician to question which prescription?

Nasotracheal suctioning is needed

A 7-year-old child is seen in the clinic, and the pediatrician documents a diagnosis of nighttime (nocturnal) enuresis. The nurse should provide which information to the parents?

Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention

A child with type 1 Diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

Normal saline infusion

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but the bleeding is excessive. Which should be the initial nursing action?

Notify the obstetrician (OB)

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action?

Notify the obstetrician (OB)

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1cm. Which nursing action is most appropriate?

Notify the obstetrician (OB)

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

Notify the primary health care provider (PHCP)

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline valve. The nurse suspects that the child is in shock. Which is the most appropriate nursing action?

Notify the primary health care provider (PHCP)

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?

Notify the primary health care provider (PHCP)

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that lasts 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 betas per minute. Which nursing action is most appropriate?

Notify the primary health care provider (PHCP)

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which action should the nurse perform immediately?

Notify the surgeon

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Observing care provided to the client without the client's permission

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy.

The maternity nurse is preparing for admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?

On the nonoperative side with the legs abducted

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?

Oranges

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

Oranges and dark green leafy vegetables

The nurse is assisting a primary health care provider (PHCP) examine a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess?

Ortolani's maneuver

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services

The mother of a 4-year old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment?

Palpating the abdomen for a mass

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?

Partial thromboplastin time

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to the circled area in the figure shown.

Patent ductus arteriosus

The nurse is reviewing the primary health care provider's (PHCP's) prescription for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history?

Peripheral vascular disease

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

Place the client in Trendelenburg's position (hips higher than the head)

A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results?

Place the normal report in the client's medical record.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in a semiprivate room at the end of the hallway

The clinic nurse reads the results of a tuberculin test (TST) on a 3-year old child. The results indicate an area of induration measuring 10mm. The nurse should interpret these results as which finding?

Positive

The mother of a 6-year old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?

Possible sexual abuse

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

Post-traumatic stress disorder

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Potassium level of 3.0 mEq/L (3.0 mmol/L)

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?

Prednisone

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from from occurring after birth in a newborn born to a woman with an untreated gonococcal infection

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?

Private room or cohort client

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms?

Projectile vomiting

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is most significant to review?

Prothrombin time

The nurse in the labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level?

Punishment and reward

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?

Reassess the client

Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochronic

The nurse has just administered ibuprofen to a child with a temperature of 102F (38.8C). The nurse should also take which action?

Remove excess clothing and blankets from the child

The nurse notes that a 6-year-old child does not recognize that objects exists when the objects are outside of the visual field. Based on this observation, which action should the nurse take?

Report the observation to the pediatrician

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Reposition the infant frequently

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

Requires nasogastric suction

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis from inadequate ventilation

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mmol/L), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

The nurse is planning care for a child with hemolytic uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure?

Restrict fluids as prescribed

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

Rhythmic respirations with periods of apnea

The nurse provides home care instructions to the parents of a child with Celiac disease. The nurse should teach the parents to include which food item in the child's diet?

Rice

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?

Safely securing the safety device straps to the side rails

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Serous drainage

The nurse is preparing for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

Side-lying

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort?

Slander

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?

Smoked salami

After a tonsillectomy the nurse reviews the surgeon's postoperative prescriptions. Which prescription should the nurse question?

Suction every 2 hours

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to to placed at the child's bedside?

Suctioning equipment and oxygen

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I am in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take?

Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?

Summer squash

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip

A client has just returned to the nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?

Supine with the residual limb supported with pillows

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse would do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant

The nurse is providing home care instructions to the parents of a 10-year old child with hemophilia. Which sport activity should the nurse suggest for this child?

Swimming

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early signs of HF?

Tachycardia

The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

Which teaching method is most effective when providing instruction to members of special populations?

Teach-back

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Test the 6 cardinal positions of gaze

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks' gestation because of which factor?

The appearance of the fetal external genitalia

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The day care nurse is observing a 2-year old child and suspects that the child may have strabimus. Which observation made by the nurse indicates the presence of this condition?

The child consistently tilts the head to see

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage?

The child has the ability to think abstractly

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

The child is 18 months old

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrusted out

The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?

The client complains of a headache and blurred vision

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30cm. How would the nurse interpret this finding?

The client is measuring normal for gestational age

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

The client is probably hyperventilating.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?

The client was found lying on the floor

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

The client who has sustained a traumatic burn

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

The client with lochia that is red and has a foul smelling odor

The nursing is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids

A 6-year old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother?

The flowers from your garden are beautiful, but should not be placed in the child's room at this time."

The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete?

The history

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-are of the perineum and asks for a pair of gloves before feeding

A diagnosis of Hodgkin's disease is suspected in a 12-year old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease?

The presence of Reed-Sternberg cells in the lymph nodes

The nurse is providing instructions to the assistive personnel (AP) regarding the care of an older client with hearing loss. What should the nurse tell the AP about older clients with hearing loss?

They respond to low-pitched tones

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

Thicken the feedings by adding rice cereal to the formula

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to the anal stage?

This stage is associated with toilet training

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

Transport the victim to the operating room for surgery

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?

Turn the child's head to the side

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

Urinary output of 20 mL/hr

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?

Uses a cup to drink

Which is most appropriate when communicating with a transgender person?

Using preferred pronouns

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine tenderness

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

Vitamin B12

The nurse is monitoring a 3-year old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP?

Vomiting

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

Weighing the diapers

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Weight loss and poor skin turgor

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes

A pediatrician has prescribed oxygen as needed for a infant with heart failure. In which situation should the nurse administer the oxygen to the infant?

When drawing blood for electrolyte level testing

The school nurse is performing pediculosis capitis (head-lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice?

White sacs attached to the hair shafts in the occipital area

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50 mm Hg (50 mmHg)