NSG 209 Exam 1
A client at 33 weeks gestation comes to ED with vaginal bleeding. Assessment reveals the following: -onset of slight vaginal bleeding at 29 wks w/ spontaneous cessation -recent onset of bright red vaginal bleeding, more than previous -no uterine contractions at present -FHR in normal range -uterus soft & nontender Bases on the assessment findings, which condition would the nurse suspect? A. placenta previa B. placental abruption C. ruptured ectopic pregnancy D. polyhydramnios
A
A client dx with a thought disorder is experiencing clang associations. Which nursing dx reflects this client's problem? A. impaired verbal communication B. risk for violence C. ineffective health maintenance D. disturbed sensory perception
A
A client dx with acute pancreatitis 5 days ago is experiencing respiratory distress. Which finding should the nurse report to HCP? A. arterial O2 of 46 B. RR 12 C. lack of adventitious lung sounds D. O2 sat 96% on RA
A
A client has the following ABG values: pH 7.52 PaO2 50 PaCO2 28 HCO3 24 Based upon the client's PaO2, which nursing clinical judgement should the nurse make? A. client is severely hypoxic B. O2 level is low but poses no risk for client C. client's PaO2 is within normal range D. client requires O2 with very low O2 concentrations
A
A client is to receive epoetin injections. What lab values should the nurse assess before giving injection? A. Hct B. partial thromboplastin time C. Hgb concentration D. prothrombin time
A
A full mental status exam should be completed if the patient: A. has a change in behavior & family is concerned B. develops dysphagia C. has a new diagnosis of Type 2 DM D. complains of insomnia
A
A manager has decided to collect data from EPIC due to an increase in CAUITs. This is an example of which step of PDSA? A. plan B. do C. study D. act
A
A nurse is caring for a client at 31 weeks who has been dx with symptomatic placenta previa. Which of the following orders by the HCP should the nurse question? A. begin oxytocin drip rate B. assess FHR every 10 min C. weigh all vaginal pads D. assess H&H
A
A nurse is caring for a client who is at 32 wks gestation & has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following meds should the nurse expect the provider to prescribe? A. betamethasone B. indomethacin C. nifedipine D. methylergonovine
A
Aphasia is best described as: A. language disturbance in speaking, writing, or understanding B. impaired ability to carry out motor activities despite intact motor function C. impaired ability to recognize or identify objects despite intact sensory function D. disturbance in executive functioning
A
During the norming stage: A. team members learn to cooperate & support one another while establishing patterns of communication & behavior B. indiv become members of a group & are anxious about their roles & responsibilities C. group is preparing to disband or facing major changes in its mission, membership or environment. Members often regress to unproductive team behaviors D. team functions at its highest level of productivity & the focus of each member shifts from indiv to group concerns
A
In the norming stage, group members tend to: A. resolve tensions and work as a team B. give up and let go of their responsibilities C. get their honest opinions out in the open D. remain awkward and stiff in their interactions
A
Medical errors account for 250,000 deaths/year. It is estimated that as many as 50% of these errors may be preventable. What steps would you take to avoid a medication error? A. Review the patient's medication admin record during bedside shift report B. ask your colleagues to get your medication so that you can give it on time C. call the pharmacist D. review the medication administration policy
A
The DNV & Joint Commission are: A. accrediting bodies B. quality research organizations C. government entities D. professional organizations
A
The mother of a post-term infant asks the nurse why the infant is being watched so closely. What is the nurse's most appropriate response? A. placenta does not function adequately as it ages B. infants born post-maturely are generally large C. delivery of the post-term infant is more difficult D. there is less amniotic fluid
A
The nurse is caring for a infant born at 42 weeks. What would the physical assessment reveal? A. dry, peeling skin B. minimal hair on head C. short, rough nails D. abundant lanugo on body
A
The nurse is preparing to teach a client with iron deficiency anemia about diet to follow after discharge. Which food should be included? A. eggs B. lettuce C. citrus fruit D. cheese
A
The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis? A. low arterial O2 when administering a high concentration of oxygen B. client has dyspnea & tachycardia & is feeling anxious C. bilateral breath sounds clear & pulse ox reading 95% D. client has JVD & frothy sputum
A
To achieve safe patient care, a culture of safety must exist. What are the characteristics of an organization with a culture of safety? A. transparency, openness, reporting of errors is rewards, blame-free environment B. honesty, studying of serious events C. privacy, reporting of errors appreciated D. blame-free environment, openness, error reporting is encouraged
A
Toyota has developed an effective & reliable process by ensuring that every step: A. adds value B. is performed by the same person each time C. is performed by colleagues with a college degree D. is performed only once
A
What is one of the things pertinent to the performing stage of group development? A. effective group function B. training new members as quick as possible C. trust between members D. power dynamics
A
When a client is dx with aplastic anemia, the nurse should assess the client for changes in which physiologic functions? A. bleeding tendencies B. I & O C. peripheral sensation D. bowel funtion
A
Which best exemplifies use of defense mechanism compensation? A. a woman feels unattractive but pursues fashion design as career B. a shy woman who abuses alcohol tells others alcohol helps her overcome her shyness C. a poorly paid employee consistently yells at his assistant for minimal mistakes D. a teenager injures an ankle playing basketball and curls into fetal position to deal with the pain
A
Which nursing dx takes priority for a client immediately after ECT? A. risk for injury related to altered mental status B. impaired social interaction related to confusion C. activity intolerance related to weakness D. chronic confusion related to side effect of ECT
A
Which procedure or test should the nurse anticipate the HCP ordering to diagnose ARDS? A. chest xray B. CBC C. airway pressure-release ventilation test D. sputum culture
A
Why does a 4 day old infant born at 33 weeks possibly need to be fed via gavage during the 1st few days of life? A. weak or absent sucking or swallowing reflex B. inability to digest food properly C. refusal to take formula via mouth D. need for larger quantity of formula at each feeding
A
You are a new nurse. The hospital where you work is committed to providing safe, high-quality care. Which of the following activities would let you know that your organization is committed to improving patient safety? A. hospital has a good catch program for staff who recognize errors & near misses B. hospital subscribes to TJC safety publications C. hospital measures performance every month, monitors quality indicators, and regularly reports on quality D. all of the above
A
A client with ARDS is on a ventilator. The client's peal inspiratory pressures & spontaneous RR are increasing, and the PO2 is not improving. What recommendation should the nurse give to the HCP? A. initiating IV sedation B. start high protein diet C. provide pain meds D. increase ventilation rate
A Client most likely is "fighting the vent"
A client had a mastectomy followed by chemo 6 mo ago. She reports that she is now "unable to concentrate" and "it seems harder & harder to finish errands because I'm so tired". What should the nurse suggest the client do to manage exhaustion? A. take frequent naps B. limit activities C. increase fluid intake D. avoid contact with others
A Client suffering from depletion of RBC from chemo. Not B because it may cause the client to become withdrawn. Should include periods of rest when experiencing fatigue.
The nurse is admitting a client with a hx of gastric bypass surgery for obesity 4 years ago presenting with pale mucous membranes & dyspnea on exertion. Vitals are: BP 104/66, HR 110, RR 27. Which type of anemia would the nurse suspect they developed? A. Vit B12 B. folic acid deficiency C. IDA D. sickle cell disease
A Gastric bypass surgery reduces ability for body to use Vit B12 from foods eaten
After failing an exam, a physician in his psych residency begins smoking a pipe and growing a beard to look like Sigmund Freud. The nurse manager, realizing the physician's insecurities, recognizes the use of which defense mechanism? A. identification B. repression C. regression D. reaction formation
A Identification is an attempt to increase self-esteem by acquiring certain attributes of an admired indiv
A client in the ED was violently attacked and raped. When discussing the incident with the nurse, the client shows no emotion related to the event. Which defense mechanism is client exhibiting? A. isolation B. displacement C. compensarion D. regression
A Isolation is separation of thought or memory from the feeling, tone, or emotion assoc with memory or event.
The client dx with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement FIRST? A. check tubing for kinks B. suction airway for secretions C. assess lip line of the ET tube D. sedate client with a muscle relaxant
A The alarm MAY indicate the client needs suctioning, but the nurse should always do the least invasive procedure FIRST when troubleshooting an alarm
The HCP ordered ABGs for the client. pH 7.38 PCO2 38 HCO3 24 PaO2 92 Which action should the nurse implement? A. continue to monitor client w/o taking any action B. encourage client to take deep breaths & cough C. admin one ampule of sodium bicarb IVP D. notify the respiratory therapist of the ABG results
A all values are normal
A client has been admitted with placental abruption. She has lost 1500 mL of blood, is normotensive, and U/S indicates approx 30% separation. The nurse documents this as which classification of abruptio placentae? A. grade 2 B. grade 4 C. grade 1 D. grade 3
A we don't need to know this
A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements indicates an understanding? SATA A. to assess cognitive ability, I should ask client to count backwards by 7 B. to assess affect, I should observe client's facial expressions C. to assess language ability, I should instruct the client to write a sentence D. to assess remote memory, I should have client repeat a list of objects E. to assess client's abstract thinking, I should ask client to identify our most recent presidents
A, B, C
A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following should the nurse assess? SATA A. occupation B. menstrual history C. childhood infectious disease D. history of falls E. recent blood transfusions
A, B, C
The nurse knows which of the following are ways to reduce waste in healthcare? SATA A. notifying the provide that an ordered test was already performed B. following facility policies to avoid med errors C. notifying the unit secretary that there are excess IV pumps in the closet D. skipping lunch breaks
A, B, C
Nurses may help to advocate for improved quality in healthcare by: SATA A. joining professional organizations B. getting active in local politics C. furthering their education D. accepting a leadership role with their employer
A, B, C, D
A client with IDA is having trouble selecting foods from hospital menu. Which foods should nurse suggest to meet iron needs? SATA A. eggs B. brown rice C. dark green veggies D. tea E. oatmeal
A, B, C, E
The nurse knows that quality health care must be: SATA A. safe B. patient-centered C. free D. timely
A, B, D
A nurse is planning care for a client who has Hgb 7.5 and Hct 21.5. Which of the following actions should the nurse include in the plan of care? SATA A. provide assistance with ambulation B. monitor O2 sat C. weight client weekly D. obtain stool specimen for occult blood E. schedule daily rest periods
A, B, D, E
A nurse is reviewing the health records of 5 clients. Which of the following clients are at risk for developing ARDS? SATA A. client who experienced a near drowning incident B. client following coronary artery bypass surgery C. client who has Hgb 15.1 D. client who has dysphagia E. client who experienced acute drug toxicity
A, B, D, E
A pregnant 36 y/o woman has presented to the ED with vaginal bleeding. While reviewing the history, the nurse suspects placenta previa when which risk factors are found in her record? SATA A. previous induced surgical abortion B. AMA C. hypotension D. smoking E. infertility treatment
A, B, D, E
A client asks a nurse about non-pharm treatments for depression. Which of the following info should the nurse include? SATA A. TMS is an FDA approved tx for depression B. CBT can help clients dealing with mild to moderate depression C. research has shown that light therapy can be used for the treatment of all types of depressive disorders D. Vagus Nerve Stimulation has been shown to be effective for depressed clients who have poor response to medications E. Electroconvulsive therapy affects brain chemistry and decreased depressive symptoms
A, B, D, E Light therapy assists with SAD, but not all types of depression
A nurse is called to the birthing room to assist with the assessment of a NB born at 32 weeks gestation. The NB birth weight is 1100 g. Which of the following are expected findings? SATA A. lanugo B. long nails C. weak grasp reflex D. translucent skin E. plump face
A, C, D
A patient participated reluctantly, answered questions w/ minimal responses & rarely made eye contact during a nursing assessment. What data should be included when documenting the assessment? SATA A. patient verbal responses B. observation the patient was uncooperative C. description of patient behavior during interview D. observations related to patient's subjective responses E. analysis of why the patient did not respond openly during interview
A, C, D
The nursery is providing shift handoff on a NB documented as small for gestational age. Which clinical manifestations would the nurse expect to communicate about this newborn? SATA A. sunken abdomen B. narrow skull sutures C. dry or thin umbilical cord D. poor muscle tone over buttocks E. increased subcutaneous fat stores
A, C, D
An assessment done in the NICU reveals a small for gestational age newborn. Which findings would the nurse connect with this gestational age variation? SATA A. poor muscle tone B. closed cranial skull sutures C. ruddy color D. sunken abdomen E. decreased amount of breast tissue
A, D, E
A client has been fired from work because of downsizing. Although clearly upset, when explaining the situation to a friend, the client states "Imagine what I can do with this extra time". Which defense mechanism is the client using? A. denil B. intellectualization C. rationalization D. suppression
B
A client with pernicious anemia asks why it is necessary to take Vit B12 injections forever. Which is the nurse's best response? A. inability to absorb vitamin b/c stomach is not producing sufficient acid B. inability to absorb vitamin b/c stomach is not producing sufficient amounts of a factor that allows for the vitamin to be absorbed C. excessive excretion of the vitamin b/c of kidney dysfunction D. an increased requirement for the vitamin b/c of rapid RBC production
B
A nurse in a clinic receives a phone call from a client seeking info about a new script for erthyropoieitin. Which of the following info should the nurse review with the client? A. client needs an erythrocyte sedimentation rate (ESR) test weekly B. client should have Hgb checked 2x week C. O2 sat levels should be monitored D. folic acid production will increase
B
A nurse in an outpatient MH clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as priority? A. coordinate holistic care with social services B. identify client's perception of their mental health status C. include client's family D. teach client about their current mental health disorder
B
A nurse in the NB nursery suspects that a new admission, a baby at 42 weeks gestation, was exposed to meconium in utero. What would lead the nurse to suspect this? A. baby is bradycardic B. baby's umbilical cord is stained green C. baby's anterior fontanel is sunken D. baby is desquamating
B
A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect? A. absent turgor B. spoon-shaped nails C. shiny, hairless legs D. yellow mucous membranes
B
After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being & satisfaction?" This is an example of leadership that values: A. quality assurance B. quality improvement C. process evaluation D. outcome evaluation
B
During the forming stage: A. team members learn to cooperate & support one another while establishing patterns of communication & behavior B. indiv become members of a group & are anxious about their roles & responsibilities C. group is preparing to disband or facing major changes in its mission, membership or environment. Members often regress to unproductive team behaviors D. team functions at its highest level of productivity & the focus of each member shifts from indiv to group concerns
B
During this stage of team development, members may find that their initial expectations of the team are far difference than the realities of trying to accomplish something together. A. forming B. storming C. norming D. performing
B
The nurse interprets which finding as an early sign of ARDS in a client at risk? A. elevated CO2 level B. hypoxia not responsive to O2 therapy C. metabolic acidosis D. severe, unexplained electrolyte imbalance
B
The nurse is developing a teaching plan for the client with aplastic anemia. Which is the most important to include? A. eat animal protein & dark green leafy veggies every day B. avoid exposure to others with acute infections C. practice yoga & meditation to decrease stress & anxiety D. get 8 hrs of sleep at night & take naps during the day
B
The nurse reports that a client dx with schizophrenia spectrum disorder is experiencing religiosity. Which client statement would confirm this finding? A. I see Jesus in my bathroom B. I read the Bible every hour so that I will know what to do next C. I have no heart. I am dead and in heaven today D. I can't read my Bible because the CIA has poisoned the pages
B
The nurse states "it's time for lunch". A client dx with schizophrenia responds, "it's time for lunch, lunch, lunch". What type of communication process is the client using & what is the underlying reason for its use? A. echopraxia, attempt to identify with the person speaking B. echolalia, attempt to acquire a sense of self & identity C. unconscious identification to reinforce weak ego boundaries D. depersonalization to stabilize self-identity
B
The purpose of QI is to continuously improve the capability of everyone involved to provide safe, high-quality patient care. What is important to know about the QI process? A. it is independent of teamwork B. it is a data-driven approach to improving process C. common safety indicators are not used to evaluate quality of care D. opportunities for QI are selected by organization leadership
B
What is a question that individuals might NOT ask during the forming stage? A. How do I fit into the group? B. How can progress be best measured? C. How will I benefit from being a part of this group? D. Do my goals align with the group's?
B
Which best exemplifies a client's use of the defense mechanism of reaction formation? A. a client feels rage at being raped at a young age, which later is expressed by joining law enforcement B. a client is unhappy about being a father, although others notice how much attention he gives his son C. a client is drinking 6-8 beers a day while still attending AA & functioning as group leader D. a client is angry that a call bell is not answered & decides to call the nurse when it is unnecessary
B
Which lab values should the nurse report to the HCP when client has anemia? A. Schilling test result, elevated B. intrinsic factors, absent C. sedimentation rate 16 D. RBC within normal limits
B
Which situation reflects the defense mechanism of projection? A. a husband has an affair then buys his wife a diamond anniversary bracelet B. a promiscuous wife accuses her husband of having an affair C. a wife, failing to become pregnant, works hard at becoming teacher of the year D. a man who was sexually assaulted as a child remembers nothing of the event
B
A nurse is caring for 4 prenatal clients in the clinic. Which of the clients is at high risk for placenta previa? SATA A. jogger with low BMI B. primigravida who smokes 1 pack a day C. infertility client who is carrying in-vitro triplets D. RN who works 12 hr shifts E. police officer on foot patrol
B, C
A neonate is being admitted to the observational nursery with the dx of postmaturity. What would the nurse expect to find with this gestational age variation? SATA A. few sole creases B. peeling, wrinkled skin C. thin umbilical cord D. meconium-stained skin & fingernails E. decreased breast tissue F. abundant lanugo G. abundant vernix caseosa
B, C, D
Which of the following are examples of indicators (problems) in healthcare QI? SATA A. poor food choices B. falls C. infections D. skin breakdown
B, C, D
A newborn is being admitted to the NICU with dx of post-term infant. Which nursing actions would be the priority? SATA A. observe for hypothermia B. assess for jaundice C. initiate blood glucose monitoring D. check for Rh incompatibility E. monitor for Hct levels
B, C, E
A nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? SATA A. encourage group to work towards goals B. define purpose of the group C. discuss termination of group D. identify informal roles of members within the group E. establish expectation of confidentiality within the group
B, C, E
A nurse is providing care for a client who has marginal abruptio placentae. Which of the following are risk factors for developing the condition? SATA A. fetal position B. blunt abdominal trauma C. cocaine use D. maternal age E. cigarette smoking
B, C, E
A 1 day old neonate at 32 wks gestation is being cared for in an isolette. The nurse assesses the morning axillary temp as 96.9. Which of the following could explain this finding? A. this is a normal temp for preterm neonate B. axillary temps are not valid for preterm babies C. the supply of brown adipose tissue is incomplete D. conduction heat loss is pronounced in baby
C
A client at 29 weeks is admitted to the unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? A. Leopold's maneuver results B. quantity of vaginal bleeding C. presence of abdominal pain D. maternal BP
C
A client dx with MDD is being considered for ECT. Which client teaching should the nurse prioritize? A. empathize with client about fears regarding ECT B. monitor for any cardiac alterations to prevent possible negative outcomes C. discuss with client & family expected short-term memory loss D. inform client that injury related to induced seizure commonly occurs
C
A client on an inpatient psych unit refuses to take meds because "the pill has a special code written on it that will make is poisonous". What kind of delusion is the client experiencing? A. erotomanic delusion B. grandiose delusion C. persecutory delusion D. somatic delusion
C
A client who follows a vegetarian diet was referred to dietician for nutritional counseling for anemia. Which client outcome indicates the client needs further education? A. client adds dried fruit to cereal & baked goods B. client cooks tomato-based foods in iron pots C. client drinks coffee or tea with meals D. client adds Vit C to all meals
C
A client with pernicious anemia is receiving Vit B12. The nurse should evaluate the client for which expected outcome of Vit B12? A. increased energy B. healed tongue & lips C. absence of paresthesia D. improved clotting time
C
A nurse documents that a client dx with schizophrenia is expressing a flat affect. What is an example of this symptom? A. client laughs when told of the death of their mother B. client sits alone and does not interact with others C. client exhibits no emotional expression D. client experiences no emotional feelings
C
A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? A. you will need to see a genetic counselor as a part of this assessment B. it's usually the female who is having trouble, so the male doesn't have to be involved C. the male is the easiest to assess & the provider will usually begin there D. think about adopting first b/c there are many babies that need good homes
C
A nurse is teaching a client who has a new script for ferrous sulfate. Which of the following information should the nurse include in the teaching? A. stools will be dark red B. take with a glass of milk if GI distress occurs C. foods high in Vit C will promote absorption D. take for 14 days
C
A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this from of group leadership when demonstrating which of the following actions? A. observes group techniques w/o interfering w/ group process B. discusses a technique and then directs members to practice technique C. asks for group suggestions of techniques and then supports discussion D. suggests techniques and asks group members to reflect on their use
C
A patient recently dx with seizure disorder plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's: A. thought process B. intellect C. judgement D. perception
C
A pregnant woman is dx with abruptio placentae. When reviewing the physical assessment, which finding would the nurse expect? A. bright red vaginal bleeding B. absence of pain C. firm, rigid uterus on palpation D. FHR within normal range
C
During the adjourning stage: A. team members learn to cooperate & support one another while establishing patterns of communication & behavior B. indiv become members of a group & are anxious about their roles & responsibilities C. group is preparing to disband or facing major changes in its mission, membership or environment. Members often regress to unproductive team behaviors D. team functions at its highest level of productivity & the focus of each member shifts from indiv to group concerns
C
During the performing stage: A. team members learn to cooperate & support one another while establishing patterns of communication & behavior B. indiv become members of a group, are anxious about roles & responsibilities, and are hesitant to participate in discussions C. team functions at its highest level of productivity & the focus of each member shifts from indiv to group concerns D. marked by conflict within the group as team members push boundaries & challenge authority in attempt to clarify the team's goals, values, and norms
C
During visiting hours, a client who is angry at her ex-husband's charges of child neglect expresses anger by lashing out at her sister in law. The nurse understands the client is demonstrating which defense mechanism? A. denial B. projection C. displacement D. rationalization
C
Mental status assessment documents: A. schizophrenia & other MH disorders B. artistic or writing ability in the mentally ill person C. emotional & cognitive functioning D. intelligence & educational level
C
The children's saying "step on a crack and you break your mother's back" is an example of what type of thinking? A. concrete thinking B. thinking using neologisms C. magical thinking D. thinking using clang associations
C
The nurse is assessing a couple who have come to the health care facility because they have been unable to conceive a child. While assessing the woman, the nurse would identify which factor as increasing the woman's risk of infertility? A. age of 25 yrs B. dysmenorrhea C. endometriosis D. patent fallopian tubes
C
The nurse is caring for a female client recovering from a sickle cell crisis. The client tells the nurse about a planned trip to Yellowstone National Park. Which response would be best for the nurse? A. that sounds like a wonderful trip to take this summer B. have you talked to your doctor about taking the trip? C. you really should not take a trip to areas with high altitudes D. why do you want to go to Yellowstone?
C
The nurse should instruct the client with Vit B12 deficiency to eat which foods to obtain the BEST supply of Vit B12? A. whole grains B. green leafy veggies C. meats & dairy products D. broccoli & brussels sprouts
C
What is the rationale for placing a preterm infant born at 34 weeks in an incubator? A. infant has small body surface to weight ratio B. heat increases to flow of O2 to the extremities C. infant's temp control mechanism is immature D. heat within the incubator facilitates drainage of mucus
C
Which group development stages finds members being more tolerabt of each other & accepting of the diverse perspectives and personalities that each member brings to the group? A. forming B. storming C. norming D. performing
C
Which situation reflects the defense mechanism of denial? A. when his twin brother excels in golf, the client begins lessens with a golf pro B. after a mother spanks her child, he pulls the cat's tail C. after years of excessive drinking, the client fails to acknowledge a problem D. client tells his family that 50% of people with his diagnosis survive
C
The nurse has placed the intubated client with ARDS in prone position for 30 min. Which factors would require the nurse to discontinue prone positioning and return client to supine? SATA A. family is coming to visit B. client has increased secretions requiring frequent suctioning C. the SpO2 & PO2 have decreased D. client is tachycardic with drop in BP E. face has increased skin breakdown & edema
C, D, E
The client dx with sickle cell is experiencing a vaso-occlusive sickle cell crisis secondary to an infection. Which medical treatments should the nurse antcipate the HCP ordering for the client? A. admin meperidine IV B. admit client to private room & keep in reverse isolation C. infuse fluids via pump D. insert foley cath with urinometer E. give O2 therapy via nasal cannula
C, E
The nurse is discharging a client dx with anemia. Which discharge instructions should the nurse teach? SATA A. take prescribed iron until it is completely gone B. monitor HR and BP at local pharmacy weekly C. have CBC checked at the HCP's office D. perform isometric exercise 3x/week E. increase amount of iron-rich foods in diet
C, E
A baby has been admitted to NICU with dx of post maturity. The nurse expects to find which of the following during the initial assessment? A. abundant lanugo B. flat breast tissue C. prominent clitoris D. wrinkled skin
D
A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? A. place a pacifier in baby's mouth B. check baby's diaper C. have mother feed the baby D. assess the RR
D
A nurse is caring for client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect b/c the baby is postmature. Which of the following statements should the nurse make? A. your baby will have excess body fat B. your baby will have flat areola w/o breast buds C. your baby's heels will easily move to his ears D. your baby's skin will have a leathery appearance
D
A nurse is working with a couple who is dealing with infertility. Which aspect would be most important for the nurse to consider? A. insurance restrictions B. family budget C. emotional limits D. culture
D
During the storming stage: A. team members learn to cooperate & support one another while establishing patterns of communication & behavior B. group is preparing to disband or facing major changes in its mission, membership or environment. Members often regress to unproductive team behaviors C. team functions at its highest level of productivity & the focus of each member shifts from indiv to group concerns D. marked by conflict within the group as team members push boundaries & challenge authority in attempt to clarify the team's goals, values, and norms
D
During which group development stage would the group evaluate the product & the lessons learned? A. storming B. norming C. performing D. adjourning
D
Nursing standards of care & the organization's policies & procedures greatly decrease risk to patient safety. Which of the following steps can a nurse take to further reduce risk? A. submit event or incident reports for near misses B. follow med admin policies & procedures C. always report significant data on care to patients & providers in a timely manner D. all of the above
D
The client dx with menorrhagia reports to the nurse of feeling listless & tired all the time. Which scientific rationale would explain these symptoms? A. pain assoc w/ menorrhagia doesn't allow client to rest B. client's symptoms are unrelated to the dx of menorrhagia C. client probably has been exposed to a virus that causes chronic fatigue D. menorrhagia has caused the client to have decreased levels of Hgb
D
The nurse is caring for an infant born at 35 weeks. What physical characteristic might the nurse expect? A. thin, long extremities B. large genitals for size C. minimal vernix caseosa D. loose, transparent skin
D
To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? A. admin O2 every 2 hrs B. turn client every 4 hrs C. admin sedatives to promote rest D. suction if cough is ineffective
D
What deficiency causes a preterm infant RDS? A. protein B. estrogen C. hyaline D. surfactant
D
Which condition would you identify as an effect of prematurity? A. enhanced ability to digest proteins B. enlarged respiratory passages C. rapid glomerular filtration rate D. fragile cerebral blood vessels
D
Which finding should the nurse expect when assessing a client with placenta previa? A. severe occipital HA B. hx of thyroid cancer C. previous premature delivery D. painless vaginal bleeding
D
Which of the following best illustrates an abnormality of thought process? A. lability B. compulsion C. aphasia D. blocking
D
Why is the post-term neonate at risk for cold stress? A. inadequate vernix caseosa B. hypoxia from deteriorated placenta C. polycythemia D. fat stores have been used in utero for nourishment
D
Your new organization is committed to quality patient care. Which of these are considered characteristics of quality health care? A. nurses use evidence-based research to guide care delivery B. nurses are respectful & responsive to their clients' individual preferences C. nurses perform an independent double check when administering chemo meds D. all of the above
D
The nurse is interviewing a client who states, "the dentist put a filling in my tooth; I now receive transmissions that control what I think and do". The nurse accurately documents that the client is experiencing: A. a delusion of persecution B. a delusion of grandeur C. a somatic delusion D. a delusion of influence
D A delusion of influence or control occurs when client believes certain objects or persons have control over their behavior
Which best exemplifies the use of defense mechanism of sublimation? A. child who has been told by parents that stealing is wrong reminds a friend not to steal B. a man who loves sports but is unable to play decides to become an athletic trainer C. having chronic asthma with frequent hospitalizations, a young girl admires her nurse and later chooses nursing as career D. a boy who feels angry and hostile decides to become a mental health therapist to help others
D Directing hostile feelings into productive activities is example of sublimation. Method of rechanneling drives or impulses into activities that are constructive
A client is admitted to the ED after a car accident but does not remember anything about it. The client is unconsciously using which defense mechanism? A. undoing B. rationalization C. suppression D. repression
D Suppression is voluntary, repression is unconscious, involuntary blocking of unpleasant feelings & experiences
A woman who has given birth to a post-term newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother? A. the NB aspirated meconium, causing the wasted appearance B. a postterm NB has begun to breakdown RBC more quickly C. NB was exposed to an infection while in utero D. with postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs
D after 42 wks gestation, the placenta loses ability to provide adequate O2 & nutrients to fetus
True or False: Nurses should be punished for honestly reporting errors.
False
A client with ARDS is showing signs of increased dyspnea. The nurse reviews the ABG: pH 7.35 PaCO2 25 HCO3 22 PaO2 95 Which finding is abnormal?
PaCO2