nclex saunders q&a pt. 6

A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting with care for the child checks the intravenous (IV) and medication supply area for what? 1. Potassium 2.NPH insulin 3.5% dextrose IV infusion 4.0.9% normal saline IV infusion

4. 0.9% normal saline IV infusion Rehydration is the initial step in resolving DKA. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose levels reach an acceptable level. IV potassium may be required depending on the potassium level, but it would not be part of the initial treatment. Test-Taking Strategy: Focus on the subject, correct IV fluid administration for a child with diabetic ketoacidosis. Eliminate option 3, knowing that dextrose would not be administered in a hyperglycemic state. Eliminate option 2 next, knowing that NPH insulin is never administered by the IV route. When considering the remaining options, recall that rehydration is the initial treatment in diabetic ketoacidosis; this will direct you to option 4.

A client had a cesarean delivery with a low transverse uterine incision. Which is the benefit of this type of incision? 1. It requires that a vertical skin incision be made. 2.It can be extended if a larger incision is needed. 3.It is the best choice with a placenta previa on the lower anterior uterine wall. 4.It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.

It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy. A low transverse uterine incision is unlikely to rupture during a subsequent labor and is the only type of uterine incision considered safe for a subsequent VBAC delivery. It cannot be extended laterally because of the location of the major uterine blood vessels in the lower uterine segment. In the presence of a placenta previa, a classic incision into the body of the uterus would be needed to prevent incising into the placental area. A suprapubic skin incision can be made with a lower uterine transverse incision.

Penicillin G procaine (Wycillin), 1 million units intramuscularly, has been prescribed for the child with a throat infection. The child's weight is 62 pounds. The safe pediatric dosage for a child that weighs greater than 60 pounds is 600,000 to 1,200,000 units daily. Which should the nurse determine about the medication dosage? 1. The dosage is too low. 2. The dosage is too high. 3. The dosage is within the safe range. 4. There is not enough information to determine the safe dosage.

The dosage is within the safe range. The child's weight is 62 pounds, which falls within the safe pediatric dosage range of 600,000 to 1,200,000 units daily. The dosage is safe.

The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made? 1. "This brace will correct my curve." 2. "I will wear my brace under my clothes." 3. "I will do back exercises at least five times a week." 4. "I will wear my brace whenever I am not sleeping."

1. "This brace will correct my curve." Bracing can halt the progression of most curvatures, although it is not curative for scoliosis. The statements in options 2, 3, and 4 represent correct understanding on the part of the child

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should the nurse suggest to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4.Provide a private room, allowing the child to bring favorite toys from home.

1. Encourage the child's parents to stay with the child. Although the preschooler may already be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may repeatedly ask when parents will be coming for a visit or may constantly want to call the parents. Option 2 is unrelated to the subject of the question and may not be appropriate for a child at risk for immunocompromise. Option 3 will increase stress related to separation anxiety. A private room may be necessary but this does not alleviate the child's fear.

The nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse understands that the hormone responsible for the development of this sign is which? 1. Estrogen 2. Prolactin 3. Progesterone 4. Human chorionic gonadotropin (hCG)

1. Estrogen The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish tinge that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy.

The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is which? 1. Flat and unfavorable for a vaginal birth 2.Rounded and most favorable for a vaginal birth 3.Narrow and oval and not the most favorable for a vaginal birth 4.Wedge-shaped and narrow and unfavorable for a vaginal birth

1. Flat and unfavorable for a vaginal birth The platypelloid pelvic shape is flattened with a wide, short oval shape and is an unfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable a shape for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The android pelvic shape is wedge-shaped and narrow and is an unfavorable shape for a vaginal birth.

The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptom should be noted in determining this finding? 1. Oliguria 2.Pale skin color 3.Severely depressed fontanels 4.Slightly dry, mucous membranes

1. Oliguria In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be very dry, the skin color would be dusky, and oliguria would be present. Options 2 and 4 describe mild dehydration. In mild dehydration, urine output would be decreased, but oliguria would not be present. Option 3 describes severe dehydration.

A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse should make which suggestion to the mother? 1. "Allow the bottle if it contains juice." 2. "Allow the bottle if it contains water." 3. "Do not allow the child to have the bottle." 4. Allow the bottle during naps but not at bedtime."

2. "Allow the bottle if it contains water." A toddler should not be allowed to fall asleep with a bottle because of the risk of dental caries. If the bottle is allowed in bed, it should contain only water.

A client receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the nurse that his urine has turned a darker color since he began to take the medication. The client wants to discontinue its use. In formulating a response to the client's concerns, how does the nurse interpret this development? 1. Indicative of developing toxicity 2. A harmless side effect of the medication 3. A result of taking the medication with milk 4. A sign of interaction with another medication

2. A harmless side effect of the medication With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Options 1, 3, and 4 are incorrect interpretations.

A client has been given a prescription for gemfibrozil (Lopid). The nurse plans to instruct the client to limit intake of which food while taking this medication? 1. Fish 2.Beef 3.Spicy foods 4.Citrus products

2.Beef Gemfibrozil is a lipid-lowering agent. It is given as part of a therapeutic regimen that also includes dietary counseling, specifically, the limitation of saturated and other fats in the diet. Therefore, the intake of red meats is limited. Fish, foods that are spicy, and citrus products do not affect the cholesterol level.

The nurse has given the client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client makes which statement? 1. "I should avoid alcohol and aspirin." 2. "I should eat a high-carbohydrate, low-fat diet." 3. "I should resume a full activity level within 1 week." 4. "I should take the prescribed amounts of vitamin K."

3. "I should resume a full activity level within 1 week." The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged clotting times, the client should take vitamin K.

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client? 1. "Why do you think this way?" 2. "Here, I'll taste the food for you." 3. "It must be frightening to you. Has something made you feel that your food is poisoned?" 4. "Your food is not poisoned. Our kitchen staff are nice people, and they are not allowed to poison people."

3. "It must be frightening to you. Has something made you feel that your food is poisoned?" Option 3 validates the client's feelings. Option 1 may place the client on the defensive and is not a facilitative technique. Option 2 involves the nurse in the client's delusion. Option 4 is incorrect because the statement is defensive and therefore nontherapeutic.

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is which? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spines 4. 1 fingerbreadth below the symphysis pubis

3. 1 cm above the ischial spines Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Options 1, 2, and 4 are incorrect.

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client? 1. Up in chair 2.Ambulation 3.Complete bed rest 4.Bathroom privileges

3.Complete bed rest Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions. Test-Taking Strategy: Note that options 1, 2, and 4 are comparable or alike and promote activity. Option 3 promotes no activity, reduces the risk of prolapsed cord, and is the correct option.

The nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. How should the nurse plan to administer the vaccine? 1. Intramuscularly in the deltoid muscle 2.Subcutaneously in the gluteal muscle 3.Subcutaneously in the outer aspect of the upper arm 4.Intramuscularly in the anterolateral aspect of the thigh

3.Subcutaneously in the outer aspect of the upper arm MMR is administered subcutaneously in the outer aspect of the upper arm. Each child should receive two vaccinations, the first between 12 and 15 months of age and the second between 4 and 6 years or 11 and 12 years.

A health care provider prescribes laboratory studies on an infant born to a human immunodeficiency virus-(HIV-) positive woman to determine the presence of HIV infection. Which laboratory study should the nurse expect to be prescribed? 1. CD4 count 2. Chest x-ray 3. Western blot 4 .p24 antigen assay

4 .p24 antigen assay True HIV infection in the infant is confirmed by a p24 antigen assay, culture of HIV, or polymerase chain reaction (PCR). A Western blot confirms the presence of HIV antibodies. The CD4 count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection.

A client with chronic atrial fibrillation is being started on amiodarone (Cordarone) as maintenance therapy for dysrhythmia suppression. The nurse reinforces instructions to the client about the medication. Which statement by the client indicates a need for further teaching? 1. "I will need to have routine follow-up with my ophthalmologist." 2. "I will need to use sunscreen and protective clothing when outside." 3. "I will periodically have blood drawn to monitor my thyroid function." 4. "I will stop taking the prescribed anticoagulant after starting this new medication."

4. "I will stop taking the prescribed anticoagulant after starting this new medication." Amiodarone is used for the dysrhythmia, atrial fibrillation. The medication will have no effect in preventing thrombus formation within the atria, so anticoagulants need to be continued. The medication increases sun sensitivity, so protective measures are essential. Thyroid function studies should be monitored because the medication can affect thyroid function. Because the medication can cause corneal microdeposits, follow-up with the ophthalmologist is important.

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client? 1. Explain the unit rules. 2. Orient the client to the unit. 3. Stabilize the client's psychiatric needs. 4. Accept the client as a person and make the client feel safe.

4. Accept the client as a person and make the client feel safe. The initial action is to make a confused and disoriented client feel safe. Orientation and explaining the unit rules are part of any admission process and do not meet the individual needs of this client. Stabilizing psychiatric needs is a long-term goal.

A client with cancer has undergone a total abdominal hysterectomy and has a Foley catheter in place. The nurse should expect to note which type of urinary drainage immediately following this surgery? 1. Colorless 2. Purulent 3. Bright red 4. Blood tinged

4. Blood tinged Because of the handling of the bladder during surgery, the urine is likely to be blood tinged. Option 1 indicates overhydration, option 2 indicates infection, and option 3 indicates active bleeding.

The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client? 1. Expect the baby to move at least 35 times in 3 hours. 2. Lie on the stomach when preparing to count the fetal movement. 3. Schedule the counting periods in the morning when the fetal movement is highest. 4. Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.

4. Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours. Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes three times a day. The woman should lie on her left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement, which is lower in the morning and higher in the evening.

The nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed which amount? 1. One pad a day 2. Two pads a day 3. Three pads a day 4. Eight pads a day

4. Eight pads a day The normal amount of lochia may vary with the individual but should never exceed eight pads a day. The average number of pads used daily is six.

The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client? 1. Group therapy 2. Medical diagnosis 3. Recreational therapy 4. Goals and objectives

4. Goals and objectives Goals and objectives are a mutual working tool between the client and the nurse and provide the foundation for the accomplishment of work between the client and nurse. Options 1, 2, and 3 are not specific to the nurse-client working relationship.

An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 am. The nurse should first determine which about the client? 1. His insurance status 2.Blood toxicology levels 3.Whether he ate his evening meal 4.Whether this is a change in his usual level of orientation

4.Whether this is a change in his usual level of orientation The nurse should first determine whether this is a change in the client's neurological status. The next item to determine should include when the client last ate. Blood toxicology levels may be needed, but the health care provider would prescribe these. Insurance information must be obtained at some point, but it is not the priority from a clinical care viewpoint.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy? 1. Rubbing the application into the skin 2. Placing the area under a heat lamp for 20 minutes 3. Applying a dry sterile dressing over the affected area 4. Covering the application with a warm, moist dressing and an occlusive outer wrap

Covering the application with a warm, moist dressing and an occlusive outer wrap The nurse can enhance penetration of topical corticosteroid therapy to the client with psoriasis by applying warm moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or a similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic side effects. The remaining options are not measures that will enhance the effectiveness of therapy.

The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client? 1. The client exhibits no signs of fetal distress. 2. The client expresses an understanding of her condition. 3. The client identifies and uses available support systems. 4. The client demonstrates compliance with activity limitations.

The client exhibits no signs of fetal distress. Option 1 clearly identifies a physiological need. Options 2, 3, and 4 may be components of the plan of care, but the physiological integrity and safety of the mother newborn dyad are the priorities. Test-Taking Strategy:Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory. Options 2, 3, and 4 deal with the psychosocial aspects of care, whereas option 1 deals with physiological and safety issues.

The nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8 mg subcutaneously every 4 hours as needed (PRN) for pain, is prescribed. The pediatric drug reference states that the safe dosage is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours. What should the nurse determine about the medication dosage? 1. The dosage is too low. 2.The dosage is too high. 3.The dosage is within the safe range. 4.There is not enough information to determine the safe dosage.

The dosage is within the safe range. Convert pounds to kilograms by dividing by 2.2, because 1 kg = 2.2 pounds.Therefore, 110 lb ÷ 2.2 = 50 kg. Then determine the dosage parameters.Dosage parameters:0.1 mg/kg × 50 kg = 5 mg0.2 mg/kg × 50 kg = 10 mgThe dosage is safe.

A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse should withhold the medication and question the prescription if the client had which concurrent prescriptions to take? 1. Ibuprofen (Advil) 2.Furosemide (Lasix) 3.Valproic acid (Depakene) 4.Tranylcypromine (Parnate)

Tranylcypromine (Parnate) The client should not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) or phenelzine (Nardil) within the past 14 days. Otherwise, the client could experience hyperpyretic crisis, seizures, or death.

A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statement by the student indicates an understanding of this hormone? 1. "It softens the muscles and joints of the pelvis." 2."It is the primary hormone of milk production." 3."It maintains the uterine lining for implantation." 4."It increases during pregnancy to stimulate basal metabolic rate."

"It increases during pregnancy to stimulate basal metabolic rate." Thyroxine increases during pregnancy to stimulate basal metabolic rates. Relaxin is the hormone that softens the muscles and joints of the pelvis. Prolactin is the primary hormone of milk production. Progesterone maintains uterine lining for implantation and relaxes all smooth muscle including the uterus.

The nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate? 1. Administer oxygen. 2.Document the findings 3.Notify the registered nurse. 4.Recheck the respiratory rate in 15 minutes.

2. Document the findings The normal respiratory rate in an infant is 30 to 60 breaths per minute. The nurse would document the findings.

The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions would be included in the plan of care? Select all that apply. 1. Maintaining bed rest 2. Elevating the affected extremity 3. Administering anticoagulants daily 4. Administering anti-inflammatory agents every 4 hours 5. Applying warm compresses to the affected area as prescribed

1. Maintaining bed rest 2. Elevating the affected extremity 5. Applying warm compresses to the affected area as prescribed Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may be recommended. Warm packs may be applied to the affected area to promote healing. Anticoagulants or anti-inflammatory agents are not needed unless the condition persists. After 5 to 7 days of bed rest, and when symptoms disappear, the woman may gradually begin to ambulate.

The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which? 1. Placing external fetal monitors so that each fetal heart rate is monitored separately 2. Placing the external fetal monitor over the fetus that is most anterior to the mother's abdomen 3. Placing the external fetal monitor over the fetus that is most posterior to the mother's abdomen 4. Placing the fetal monitor so that one fetus is monitored for a 15-minute period followed by a 15-minute fetal monitoring period for the second fetus

1. Placing external fetal monitors so that each fetal heart rate is monitored separately In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Options 2, 3, and 4 are incorrect because these actions would not provide information regarding the status of each fetus.

The nurse prepares to administer digoxin (Lanoxin) to a 3-year-old with a diagnosis of heart failure and notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate? 1. Hold the medication. 2.Administer the digoxin. 3.Notify the registered nurse. 4.Recheck the apical heart rate in 15 minutes.

2. Administer the digoxin. The normal apical heart rate for a 3-year-old is 80 to 125 beats per minute. Because the apical heart rate is within normal range, options 1, 3, and 4 are inappropriate.

The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which should the nurse anticipate to be prescribed by the health care provider? 1. A repeat rubella titer in 2 weeks 2. Administration of a subcutaneous rubella virus vaccine 3. Administration of a subcutaneous rubella virus vaccine for the newborn 4. Counseling to the mother and informing the mother that this is a normal titer

2. Administration of a subcutaneous rubella virus vaccine A blood sample for rubella titer is done on all women in the antepartum or postpartum period. A postpartum woman with a titer of 1:8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II). This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine. Test-Taking Strategy: Knowledge regarding the subject, the expected titer results for rubella, is required to answer this question. Recalling that a titer of 1:8 or less requires the administration of a subcutaneous rubella virus vaccine to the mother postpartum will direct you to option 2.

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? 1. The client holds the walker using the handgrips. 2. The client advances the walker with reciprocal motion. 3. The client leans forward slightly when advancing the walker. 4. The client supports body weight on the hands while advancing the weaker leg.

2. The client advances the walker with reciprocal motion. The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks, thus the client would not be supporting the weaker leg with the walker during ambulation

A client is receiving diazepam (Valium) for its skeletal muscle relaxant effects. The nurse should monitor this client for which side effect of this medication? 1. Headache 2.Incoordination 3.Urinary retention 4.Increased salivation

2.Incoordination Diazepam is a centrally acting skeletal muscle relaxant. Incoordination and drowsiness are common side effects resulting from this medication. The other options are incorrect.

A health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse reinforces instructions to the mother to use which procedure for eye patching? 1. Place the patch on both eyes. 2.Place the patch on the left eye. 3.Place the patch on the right eye. 4.Alternate the patch from the right to left eye hourly.

2.Place the patch on the left eye. Eye patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the "good" eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.

The nurse is caring for a client with myasthenia gravis who has received edrophonium (Enlon) intravenously to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. The nurse's response is based on the understanding that the duration is usually how many minutes? 1. 5 2. 15 3. 30 4. 60

3. 30 Edrophonium may be given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication and lasts for about 30 minutes.

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate? 1. The neonate is lethargic. 2. The neonate sleeps quietly. 3. The neonate cries incessantly. 4. The neonate is easy to console when crying.

3. The neonate cries incessantly. A neonate born to a woman who is addicted to drugs is irritable, may cry incessantly, and be difficult to console. The neonate would hyperextend and posture rather than cuddle when being held.

The nurse has reinforced discharge instructions to the client who has had ocular surgery of the right eye. The nurse determines that the client needs further teaching if the client states which? 1. "I will wear an eye shield at night." 2. "I will sleep on the back or left side." 3."I will wear sunglasses during the day." 4."I will call the health care provider if a temperature of 99° F is present."

4."I will call the health care provider if a temperature of 99° F is present." The client is generally taught to report a temperature of 101° F or greater. The client should also report chills, pain unrelieved by medication, bleeding, foul-smelling drainage, or redness at the surgical site. The client should wear eyeglasses during the day and an eye shield at night to protect the eye. The client should lie on the back or the nonoperative side, unless otherwise instructed by the surgeon.

The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse should suggest which to the mother? 1. "Avoid a nap during the day." 2."Allow the child to set bedtime limits." 3."Allow the child to have temper tantrums." 4."Inform the child of bedtime a few minutes before it is time for bed."

4."Inform the child of bedtime a few minutes before it is time for bed." Most toddlers take an afternoon nap and until approximately age 2, some also require a morning nap. Toddlers often resist going to bed. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics. Bedtime protests may be reduced by warning the child of bedtime a few minutes before the time.

The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching? 1. Milk 2.Potatoes 3.Cantaloupe 4.Fresh spinach

4.Fresh spinach Dietary sources of iron include lean meats; liver; shellfish; dark green, leafy vegetables such as spinach; legumes; whole grains and enriched grains; cereals; and molasses. Milk is high in calcium and also contains phosphorus. Cantaloupe and potatoes are high in vitamin C.

An older client is taking multiple medications for a variety of health problems. The nurse should monitor the results of which most important laboratory test(s) when evaluating adverse effects of medication therapy in the older adult? 1. Creatinine 2. Arterial blood gases 3. Complete blood cell count 4. Hemoglobin and hematocrit

Creatinine Creatinine should be most closely monitored because it relates to kidney function. Because many medications are excreted by the kidneys, that makes this the laboratory test of choice for ongoing monitoring. Option 3 is part of option 4, whereas arterial blood gases are not generally measured unless there is a specific problem with oxygenation.

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect? 1. Less pressure on her cervix 2. Increased efficiency of contractions 3. Decreased number of contractions 4. The need for increased blood pressure (BP) monitoring

Increased efficiency of contractions Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not create the need for increased monitoring of the BP.

The nurse is developing a plan of care for a child with autism. The nurse should identify which priority problem for this child? 1. Risk for injury 2. Inability to interact socially 3. Troubling thought processes 4. Inability to verbally communicate

1. Risk for injury Risk for injury related to an inability to anticipate danger, a tendency for self-mutilation, and sensory perceptual deficits are the priority concerns. Inability to interact socially, troubling thought processes, and inability to verbally communicate are also appropriate problems for the child with autism, but the priority is the risk for injury.

The nurse is employed in a mental health clinic that specifically manages somatization disorders. The nurse understands that which is a characteristic of a somatization disorder? 1. The client has multiple physical complaints. 2. The client performs rituals or repetitive behaviors. 3. The client is preoccupied with persistently intrusive thoughts and ideas. 4. The client experiences disruption in integrative functions of memory, consciousness, or identity.

1. The client has multiple physical complaints. A somatization disorder is characterized by multiple physical complaints involving numerous body systems; the cause of the complaints is presumed to be psychological. A compulsion is the performance of rituals or repetitive behavior designed to prevent some event, divert unacceptable thoughts, and decrease anxiety. A dissociative disorder is characterized by a disruption in integrative functions of memory, consciousness, or identity. With an obsession, the client is preoccupied with persistently intrusive thoughts and ideas.

The nurse should monitor for which laboratory result as indicating an adverse reaction in the client with endometrial cancer who is receiving chemotherapy? 1. Hemoglobin 12.5 g/dL 2. Platelet count 20,000 cells/mm3 3. Blood urea nitrogen 20 mg/dL 4. White blood cell count 7000 cells/mm3

2. Platelet count 20,000 cells/mm3 A normal platelet count ranges from 150,000 cells/mm3 to 400,000 cells/mm3. A platelet count of 20,000 cells/mm3 places the client at severe risk for bleeding. All of the other values are within normal limits.

An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation? 1. Hypoglycemia 2. Alzheimer's disease 3. Medication dosage error 4. Impaired circulation to the brain

2. Alzheimer's disease Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Medication use, hypoglycemia, and impaired cerebral circulation require evaluation to determine if they play a role in causing the client's current symptoms.

A client is receiving anticonvulsant therapy with phenytoin (Dilantin). The nurse plans to monitor the results of which laboratory test closely? 1. Serum sodium 2.Serum potassium 3.Blood urea nitrogen 4.Complete blood cell count

4. Complete blood cell count The nurse would monitor the client's complete blood cell counts because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other values that warrant monitoring include serum calcium levels and the results of urinalysis, and hepatic and thyroid function tests.

The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client? 1. Fear 2.Grieving 3.Acute pain 4.Impaired gas exchange

4.Impaired gas exchange The priority should always deal with airway. Although options 1, 2, and 3 are also appropriate concerns for this client, they are not the priority and assume a lesser priority than impaired gas exchange.

The nurse overhears the term sundowning used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. Of which diagnosis is sundowning a symptom? 1. Schizophrenia 2. Alzheimer's disease 3. Parkinson's disease 4. Acquired immunodeficiency syndrome

2. Alzheimer's disease The term sundowning or sundown syndrome refers to a pattern of disorientation in which the client is more oriented during the daytime hours and more disoriented at night. It is seen often in clients with Alzheimer's disease. It is not a characteristic of the conditions noted in the other options.

The nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? 1. A soft and boggy uterus 2. Changes in the shape of the uterus 3. Maternal complaints of severe uterine cramping 4. The umbilical cord shortens in length and changes in color

2. Changes in the shape of the uterus Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness but not sudden uterine cramping.

The nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which should the nurse expect to note in the child? 1. Swelling of the parotid gland 2.Petechiae spots located on the palate 3.A fiery red edematous rash on the cheeks 4.Small blue-white spots noted on the buccal mucosa

2.Petechiae spots located on the palate Forchheimer sign refers to petechiae spots, which are reddish and pinpoint and located on the soft palate. Small blue-white spots noted on the buccal mucosa are known as Koplik's spots seen in rubeola. A fiery red edematous rash on the cheeks, also called "slapped cheeks" is seen in erythema infectiosum. Swelling of the parotid gland is seen in mumps.

Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching? 1. "The rash usually begins behind the ears at the hairline." 2. "Small blue-white spots with a red base may appear in the mouth." 3. "The infectious period ranges from 10 days before symptoms start to 15 days after the rash appears." 4. "Respiratory symptoms such as a profuse runny nose, cough, and fever occur before the development of a rash."

3. "The infectious period ranges from 10 days before symptoms start to 15 days after the rash appears." The infectious period for rubeola ranges from 1 to 2 days before the onset of symptoms to 4 days after the rash appears. Options 1, 2, and 4 are accurate descriptions of rubeola. Option 3 describes the infectious period for rubella (German measles).

The nurse determines that a client with which history is most at risk for endometrial cancer? 1. Surgical interventions 2. Steroid replacement therapy 3. Estrogen replacement therapy 4. Occupational exposure to dust

3. Estrogen replacement therapy Endometrial cancer is related to the hormone estrogen because estrogen is the primary stimulant of endometrial proliferation. Steroid replacement therapy, occupational exposure to dust, and surgical interventions are not considered to be risk factors for endometrial cancer.

A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report? 1. The child's hands 2. The child's heart 3. The child's cervical spine 4. The child's chest and lungs

3. The child's cervical spine Children with Down syndrome frequently have instability of the space between the first two cervical vertebrae. They require diagnostic studies (an x-ray of the cervical spine) to determine if this is present before participating in activities that put pressure on the head and neck, which could cause spinal cord compression. Options 1, 2, and 4 are not necessary.

Diphenhydramine hydrochloride (Benadryl) 25 mg orally every 6 hours is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. What should the nurse determine about the medication dosage? 1. The dosage is too low. 2.The dosage is too high. 3.The dosage is within the safe range. 4.There is not enough information to determine the safe dosage.

3. The dosage is within the safe range. Calculate the dosage parameters using the safe dosage range identified in the question and the child's weight in kilograms. Next, determine the total daily dosage.Dosage parameters: 5 mg/kg × 25 kg = 125 mg/dayDosage frequency: 25 mg × 4 doses = 100 mg/dayThe dosage is safe.

The nurse is working with an older client and family about discharge following hospitalization. When initiating discussions with the group, the nurse understands that older persons usually prefer which? 1. To live alone 2. To live with their children 3. To live in long-term care facilities 4. To live independently, but close to their children

4. To live independently, but close to their children Most older people prefer to maintain their independence while having the resource of children or family nearby to help in times of need. In general terms, the other options are not as favorably received by the older person, but this would also depend on the specific client and the specific situation.

A client with narcolepsy has been prescribed a central nervous system (CNS) stimulant. The client complains to the nurse that he cannot sleep well anymore at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which time schedule? 1. After dinner each day 2. Just before going to bed 3. Two hours before bedtime 4. At least 6 hours before bedtime

4. At least 6 hours before bedtime A central nervous system (CNS) stimulant acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Taking the medication at the time frames indicated in options 1, 2, and 3 will prevent the client from sleeping because of the stimulant properties of the medication.

The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is which? 1. Flat and unfavorable for a vaginal birth 2. Rounded and most favorable for a vaginal birth 3. Narrow and oval and not the most favorable for a vaginal birth 4. Wedge-shaped and narrow and unfavorable for a vaginal birth

4. Wedge-shaped and narrow and unfavorable for a vaginal birth The android pelvic shape is wedge-shaped and narrow and is an unfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is an unfavorable shape for a vaginal birth.

The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation? 1. The spouse if grieving because of the loss of the baby. 2. The spouse is anxious about the reason the baby died. 3. The spouse does not have any knowledge about the disease process. 4.The spouse lacks hope because of the loss of the baby and illness of his wife.

4.The spouse lacks hope because of the loss of the baby and illness of his wife. A person who lacks hope experiences hopelessness and sees no way out of the situation except for death. There are no data in the question that support the situation of grieving, deficient knowledge, or anxiety.

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period the nurse notes bloody drainage from the nasogastric (NG) tube. Which action should the nurse take? 1. Irrigate the NG tube. 2. Measure abdominal girth. 3.Continue to monitor the drainage. 4.Ask the registered nurse to notify the health care provider (HCP) immediately.

Continue to monitor the drainage. Following gastrectomy, drainage from the NG tube is normally bloody for 24 hours postoperatively and then changes to brown-tinged, then to yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. There is no need to notify the HCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, an NG tube should not be irrigated.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicates to the nurse favorable resolution of the fat embolus? 1. Minimal dyspnea 2. Clear chest x-ray 3. Oxygen saturation 85% 4. Arterial oxygen level of 78 mm Hg

2. Clear chest x-ray A clear chest x-ray is a favorable indicator that fat embolus is resolving. When fat embolism occurs, the chest x-ray has a "snowstorm" appearance. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%.

The nurse is evaluating the developmental level of a 2-year-old child. Which should the nurse expect to observe in this child? 1. Uses a fork to eat 2. Holds a cup in one hand 3. Pours own milk into a cup 4. Uses a knife for cutting food

2. Holds a cup in one hand By 2 years of age, the child can hold a cup in one hand and use a spoon well. By the age of 3 to 4 years, the child begins to use a fork. By the end of the preschool period, the child should begin to use a knife for cutting. Pouring liquids into a cup is a skill that requires fine motor development.

The nurse is told by an older woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6:00 pm. The nurse's response should be guided by which knowledge? 1. Incontinence is to be expected in old age. 2. Incontinence at any age deserves urological attention. 3. Older people do not need as much fluid intake as younger people. 4. The client is the best judge of how much fluid she should or should not drink.

2. Incontinence at any age deserves urological attention. Urinary incontinence requires evaluation as to the cause so that appropriate treatment can be begun. Options 1 and 3 are incorrect assumptions and represent stereotypical thinking. Option 4 may be true generally but may not apply because of the development of this new problem.

The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal? 1. Minimize the possibility of preterm labor. 2. Reduce the risks of anemia during pregnancy. 3. Avoid further stress on the maternal immune system. 4. Minimize the risk of premature rupture of membranes.

3. Avoid further stress on the maternal immune system. The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Option 3 identifies the primary nursing management subject for the HIV-infected client.

The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication? 1. Pain 2.Deafness 3.Nuchal rigidity 4.A red, swollen testicle

3. Nuchal rigidity (stiff neck, is an inability to flex the neck forward due to rigidity of the neck muscles) The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. A red, swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication.

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority? 1. Encourage the client to move the arms. 2. Look for organic causes of the paralysis. 3.Encourage the client to talk about feelings. 4.Refer the client for a psychiatric evaluation.

2. Look for organic causes of the paralysis. The first priority is to rule out any neurological disorders. After it has been determined that the paralysis has no physiological basis, then further psychiatric evaluation can be done. The client should be encouraged to talk about feelings, but this is not the priority option. Encouraging the client to move the arms has no beneficial or associated effect in this situation.

The mother of a child arrives at the clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and a culture is sent to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, which should require further investigation? 1. Possible trauma 2. Possible sexual abuse 3. The presence of an allergy 4. The presence of a respiratory infection

2. Possible sexual abuse A diagnosis of chlamydial conjunctivitis in a non-sexually active child should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis but not chlamydial conjunctivitis.

The nurse is reviewing the medical history of a client admitted to the hospital with a diagnosis of colorectal cancer. The nurse understands that which information documented in the medical history is an unassociated risk factor of this type of cancer? 1. Family history of colon cancer 2. Regular consumption of a high-fiber diet 3.A history of inflammatory bowel disease 4.Regular consumption of a diet high in fats and carbohydrates

2. Regular consumption of a high-fiber diet Colorectal cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10 years' duration.

The nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse should document the ulcer as which category? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

2. Stage II A stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, shallow crater, or a blister. A stage I ulcer is a reddened area that doesn't blanch but has intact skin. Stages III and IV ulcers are full thickness, or full thickness with necrosis or damage to muscle, bone, or supportive tissue, respectively.

A health care provider has prescribed phenobarbital sodium (Luminal Sodium), 25 mg orally twice daily for a child with febrile seizures. The child's weight is 7.2 kg. The safe pediatric dosage is 1 to 6 mg/kg/day. What should the nurse determine about the medication dosage? 1. The dosage is too low. 2. The dosage is too high. 3.The dosage is within the safe range. 4.There is not enough information to determine the safe dosage.

2. The dosage is too high Calculate the dosage parameters using the safe dosage range identified in the question and the child's weight in kilograms. Next determine the total daily dosage.Dosage parameters:1 mg/kg/day × 7.2 kg = 7.2 mg/day6 mg/ kg/day × 7.2 kg = 43.2 mg/dayDosage frequency: 25 mg × 2 doses = 50 mg/dayThe dosage is too high.

The nurse is caring for a client with a skin infection who is receiving amoxicillin (Amoxil) 500 mg every 8 hours. Which sign/symptom indicates to the nurse that the client is experiencing a frequent side effect related to the medication? 1. Fever 2. Vaginal drainage 3. Severe watery diarrhea 4. Severe abdominal cramps

2. Vaginal drainage Amoxicillin is a type of penicillin. Frequent side effects include mild gastrointestinal disturbances, headache, and oral or vaginal candidiasis. A less common but more harmful adverse effect that can occur includes superinfection, such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms include severe abdominal cramps, severe watery diarrhea, and fever.

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response should be therapeutic? 1. "Only you can help?" 2. "You decided not to take your medication?" 3. Do you recall needing to be hospitalized because you stopped your medication?" 4. If you can make this wise observation, you probably don't need your medication any longer."

3. Do you recall needing to be hospitalized because you stopped your medication?" Noncompliance with antipsychotic medication is one of the chief reasons that clients with schizophrenia have relapses. The nurse teaches the client with schizophrenia to identify the causes of relapse. In option 1, the nurse is employing restating, which, although therapeutic, is not useful to this client and to this client's situation. In option 2, the nurse is again using restating. In option 4, the nurse is using an illogical, judgmental, and biased response, which is not therapeutic.

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time? 1. Inability to cope 2. Deficient sensory perception 3. Fear about what is happening 4. Lack of control over the situation

3. Fear about what is happening The mother is anxious and frightened and the most appropriate problem for the client at this time is fear about what is happening. No data in the question support the problems noted in the other options although they may be a consideration for this client at some point during the hospitalized experience.

The nurse is working with an older client who has a diagnosis of depression. To work most effectivelywith this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply. 1. Depression in an older person is rarely treatable. 2. Depression in an older person is considered a normal finding. 3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations.

3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations. Depression is treatable in an older client. The nurse should be aware of the implications of depression, such as physical manifestations, the possibility of dementia, and suicide risk. Therefore, the statements in options 3, 4, and 5 are accurate. Depression is never a normal finding, regardless of the client's age.

The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement? 1. One half the distance between the antecubital fossa and the shoulder 2. One third the distance between the antecubital fossa and the shoulder 3. Two thirds the distance between the antecubital fossa and the shoulder 4. One quarter the distance between the antecubital fossa and the shoulder

3. Two thirds the distance between the antecubital fossa and the shoulder The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values and those that are too large will cause inaccurate low values. The cuff should cover two thirds the distance between the antecubital fossa and the shoulder.

The nurse is preparing to admit a client diagnosed with obsessive-compulsive disorder (OCD) to the mental health unit. The nurse should observe this client for which behavioral characteristic(s)? 1. Extreme fright 2. Suspicion and hostility 3. Inflexibility and rigidity 4. Flexibility and adaptability

3. Inflexibility and rigidity Rigidity and inflexibility are behavioral characteristics of the client with obsessive-compulsive disorder. Clients are not usually hostile unless they are prevented from performing the obsession or compulsion because that is what decreases the anxiety. The other options are incorrect because they are not characteristics of obsessive-compulsive disorder.

The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which medication is prescribed? 1. Subcutaneous administration of terbutaline 2. Oral intake of 15 mg of warfarin (Coumadin) daily 3. Intravenous infusion of heparin sodium 5000 units daily 4. Subcutaneous administration of heparin sodium 5000 units daily

4. Subcutaneous administration of heparin sodium 5000 units daily Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antepartum, intrapartum, and postpartum periods. Warfarin is contraindicated during pregnancy because it crosses the placental barrier, causing potential fetal malformations and hemorrhagic disorders. Heparin sodium, which does not cross the placental barrier, is safe to use during pregnancy and would be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only. Test-Taking Strategy: Use knowledge of the subject, medications that are safe during pregnancy. Eliminate options 1 and 2 first because warfarin is contraindicated and terbutaline is indicated for preterm labor management only. From the remaining options, select option 4 because of the word subcutaneous.

The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? 1. Selecting shoes that have firm nonskid soles 2.Applying nonskid strips on areas that get wet 3.Installing telephones in several rooms of the house 4.Maintaining body weight at or above minimum recommended levels

4.Maintaining body weight at or above minimum recommended levels Maintaining body weight at or above minimum recommended levels is a primary prevention measure. Additional prevention measures include achieving optimal calcium intake, performing regular exercise, avoiding smoking and alcohol consumption, avoiding a high-sodium and high-protein diet, and consuming adequate amounts of vitamin D. Options 1, 2, and 3 include secondary prevention measures.

An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which is consistent with normal findings? 1. Protein 2. Glucose 3. Red blood cells 4 White blood cells

3. Red blood cells The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 3 per mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) are normally present in CSF. Test-Taking Strategy: To answer this question accurately it is necessary to be familiar with the subject, the normal components of CSF. Remember that normal cerebrospinal fluid has no red blood cells in the CSF.

The nurse is collecting data from a client who is suspected of having mittelschmerz. Which should the nurse expect to note? 1. Profuse vaginal bleeding 2. Pain that occurs during intercourse 3. Sharp pain located on the right side of the pelvis 4. Client complains of pain at the beginning of menstruation

3. Sharp pain located on the right side of the pelvis Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days, and slight vaginal bleeding may accompany the discomfort.

The nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. Which is the appropriate procedure to elicit a Kernig's sign? 1. Tap the facial nerve and check for spasm. 2. Extend the leg and knee and check for pain. 3. Compress the upper arm and check for tetany. 4. Bend the head toward the knees and hips and check for pain

Extend the leg and knee and check for pain. Kernig's sign is pain that occurs with extension of the leg and knee. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distall

A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother? 1. Immediately 2.Before the child is 3 years old 3.Shortly before the child starts school 4.Just before the child begins to learn to read

2. Before the child is 3 years old In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. It is most often indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 3 years old. Test-Taking Strategy: Focus on the subject, strabismus. Option 1 can be eliminated first because of the word immediately. Options 3 and 4 can be eliminated next because they address a similar time frame.

A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student should include which correct item in the discussion? 1. HIV primarily attacks the hematological system. 2.HIV virus attacks the immune system by destroying T lymphocytes. 3.Most newborns of HIV-positive women test positive for HIV virus. 4.In HIV, the B cells are depleted and cannot signal T4 cells to form protective antibodies.

2. HIV virus attacks the immune system by destroying T lymphocytes. The virus attacks the immune system by destroying T lymphocytes. Children born to HIV-positive women test positive for HIV antibody, not HIV virus. This is actually a measure of maternal antibody and not indicative of true infection. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus.

The nurse assists a pregnant client with cardiac disease in identifying resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to accomplish which? 1. Help the mother prepare for labor and delivery. 2. Reduce excessive maternal stress and fatigue. 3. Avoid exposure to potential pathogens and resulting infections. 4. Prepare the 18-month-old child for maternal separation during hospitalization.

2. Reduce excessive maternal stress and fatigue. A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. Use of appropriate resources will help the client avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. Options 1, 3, and 4 are not primary purposes for use of resources with the pregnant cardiac client. Test-Taking Strategy: Focus on the subject of the question, noting the client's diagnosis. Also noting the word primarily in the question will assist in directing you to option 2.

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likelyrepresents which? 1. Satisfaction with self 2. A form of functional coping 3. Protection from the risk of intimacy 4. Long-term lack of compliance with weight programs

3. Protection from the risk of intimacy Clients who become obese after a trauma as described in the question may be trying to portray themselves as "fat and unattractive." This would allow them to protect themselves from the risk of intimacy. Options 1 and 2 are incorrect interpretations. There are not enough data in the question to support option 4.

During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic? 1. "Don't worry so much." 2."Everything is going to be all right." 3."I can see that you are upset about this. Let's talk about this some more." 4."Why are you having so much trouble with maintaining realistic behavior?"

3."I can see that you are upset about this. Let's talk about this some more." The correct response acknowledges the client's feelings. The remaining options do not use therapeutic communication skills. Options 1 and 2 are clichés that do not acknowledge the client's feelings. Option 4 is nontherapeutic and requires an explanation from the client.

The nurse is caring for a client with glaucoma who is receiving acetazolamide (Diamox Sequels) daily. Which sign/symptom indicates to the nurse that the client is experiencing an adverse effect related to the medication? 1. Diarrhea 2. Irritability 3. Lacrimation 4.Low back pain and dysuria

4.Low back pain and dysuria Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and are manifested by dark urine and stools, jaundice, pain in the lower back, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression also may occur. The remaining options are not adverse effects of the medication.

The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data would be included? 1. The client's fear related to the use of the crutches 2.The client's feelings about the restricted mobility 3.The client's understanding of the need for increased mobility 4.The client's vital signs, muscle strength, and previous activity level

4.The client's vital signs, muscle strength, and previous activity level Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. The previous activity level will provide information related to the tolerance of activity. Options 1, 2, and 3 are also important, but physiological needs take precedence over psychosocial needs.

The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting which? 1. Opisthotonos 2. Decorticate rigidity 3. Decerebrate rigidity 4. Flaccid quadriplegia

1. Opisthotonos Opisthotonos is a prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are extended stiffly with plantar flexion. The teeth are clenched and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brain stem.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. According to the nurse, what is the purpose of progesterone? 1. Progesterone maintains the uterine lining for implantation. 2. Progesterone stimulates metabolism of glucose and converts the glucose to fat. 3. Progesterone prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. 4. Progesterone stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.

1. Progesterone maintains the uterine lining for implantation. Progesterone maintains the uterine lining for implantation and relaxes smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site? 1. Dry, sterile dressings 2. Hydrocolloid dressings 3. Moist, sterile saline dressings 4. Half-strength povidone-iodine (Betadine) dressings

3. Moist, sterile saline dressings The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Options 1, 2, and 4 are incorrect.

client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which? 1. Pressure on the spinal cord 2. Pressure on the spinal nerve root 3. Muscle spasm in the area of the herniated disk 4. Excess cerebrospinal fluid production in the area

3. Muscle spasm in the area of the herniated disk Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knifelike, and localized in the affected area. Options 1, 2, and 4 are incorrect.

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position? 1. Flat with the knee gatch raised 2. In semi-Fowler's position with the foot of the bed flat 3. In high-Fowler's position with the foot of the bed flat 4. In semi-Fowler's position with the knee gatch slightly raised

4. In semi-Fowler's position with the knee gatch slightly raised Clients with low back pain are often more comfortable when placed in semi-Fowler's position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi-Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Option 1 stretches the lower back.

A health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child should check which highest priority item before administration of the potassium? 1. Weight 2.Urine output 3.Temperature 4.Blood pressure

Urine output The priority assessment would be to check the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, it should not be administered. Although options 1, 3, and 4 may be a component of the data collected, they are not specifically related to the administration of this medication. Note the strategic words, highest priority. Recalling that the kidneys play a strategic role in the excretion and reabsorption of potassium will direct you to option 2. Review: Hypertonic dehydration and potassium administration.

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury? 1. Have the police take the adolescent's gun away. 2. Explore the adolescent's knowledge of gun safety. 3. Refer the adolescent to a firearm safety class sponsored by the hospital. 4. Have the adolescent watch a video on the tragedies of improper firearm usage.

Explore the adolescent's knowledge of gun safety. One of the leading causes of accidental deaths in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data about a firearm safety history, which is done in option 2. Option 3 may then be indicated. Option 4 may or may not be effective at some point for this client. Option 1 is unreasonable.

The nurse has reinforced instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client makes which statement? 1. "Stop and start the stream of urine several times during a voiding." 2. "Tighten perineal muscles for up to 10 seconds several times a day." 3. "Tighten perineal muscles for up to 5 minutes three or four times a day." 4."Begin voiding and then stop the stream, holding residual urine for an hour."

4."Begin voiding and then stop the stream, holding residual urine for an hour." Kegel exercises strengthen the perineal floor and are useful to prevent and manage cystocele, rectocele, and enterocele. There are several acceptable ways to perform Kegel exercises. These involve starting and stopping the flow of urine either once for up to 5 minutes, or several times during a single voiding for about 5 seconds. Because the muscles that control urination also are involved in defecation, these exercises also can be done once during defecation. Otherwise, they may be done by holding perineal muscles taut for up to 10 seconds several times a day, or for 5 minutes three or four times a day. Option 1 is not a correct method for performing Kegel exercises. Residual urine should not be held in the bladder for lengthy periods because it could promote urinary tract infection.

The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate? 1. Elevate the head of the bed. 2. Obtain a hemoglobin and hematocrit level. 3. Instruct the mother to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the mother until the feelings of lightheadedness and dizziness have subsided.

3. Instruct the mother to request help when getting out of bed. Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness and dizziness are signs that caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times getting out of bed. Option 1 is not a helpful action and could cause increased dizziness. Option 2 requires a health care provider's prescription. Option 4 is unnecessary. Test-Taking Strategy: Focus on the subject, client safety. Option 4 is inappropriate and should be eliminated first. Elevating the head of the bed is not a helpful nursing intervention to treat these symptoms. From the remaining options, recall that safety is a primary need. This should assist in directing you to the correct option.

The nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother what information? Select all that apply. 1. "Bladder control is usually achieved before bowel control." 2."The child should not be forced to sit on the potty for long periods." 3."The ability of the child to remove clothing is a sign of physical readiness." 4."Waiting until the child is 24 to 30 months old makes the task considerably easier." 5."At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents."

2."The child should not be forced to sit on the potty for long periods." 3."The ability of the child to remove clothing is a sign of physical readiness." 4."Waiting until the child is 24 to 30 months old makes the task considerably easier." 5."At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents." Waiting until the child is 24 to 30 months old makes the task considerably easier because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents. Bowel control typically occurs before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness.

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period? 1. "The infectious period is unknown." 2."The infectious period ranges from 2 weeks or less up to several months." 3."The infectious period is 10 days before the onset of symptoms to 15 days after the rash appears." 4."The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."

"The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions." Varicella is known as chickenpox. The infectious period for varicella is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions. In roseola, the infectious period is unknown. Option 2 describes diphtheria. Option 3 describes rubella.

The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action? 1. Remove the IV. 2. Check for a blood return. 3. Apply a warm compress. 4. Measure the area of infiltration.

1. Remove the IV. Blanching, coolness, and edema of the IV site are signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed.