nursing comp exam 4 tb

A 27-year-old married woman is 16 weeks pregnant and has an abnormally low maternal serum alpha-fetoprotein test. Which statement indicates that the couple understands the implications of this test result? 1. We have decided to have an abortion if this baby has Down syndrome. 2. If we hadnt had this test, we wouldnt have to worry about this baby. 3. Ill eat plenty of dark green leafy vegetables until I have the ultrasound. 4. The ultrasound should be normal because Im under the age of 35.

1

A 28-year-old woman has been an insulin-dependent diabetic for 10 years. At 36 weeks gestation, she has an amniocentesis. A lecithin/sphingomyelin (L/S) ratio test is performed on the sample of her amniotic fluid. Because she is a diabetic, what would an obtained 2:1 ratio indicate for the fetus? 1. The fetus may or may not have immature lungs. 2. The amniotic fluid is contaminated. 3. The fetus has a neural tube defect. 4. There is blood in the amniotic fluid.

1

A cesarean section is ordered for a pregnant client. Because the client is to receive general anesthesia, what is the primary danger with which the nurse is concerned? 1. Fetal depression 2. Vomiting 3. Maternal depression 4. Uterine relaxation

1

A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room.

1

A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with hand washing. 2. Assist the client back to bed. 3. Change the client's bed. 4. Leave the client's room.

1

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements

1

Which of the following is a common barbiturate used in labor? 1. Seconal 2. Valium 3. Phenergan 4. Vistaril

1

The primary physician orders a narcotic analgesic for a client in labor. Which situations would lead the nurse to hold the medication? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Contraction pattern every 3 minutes for 60 seconds 2. Fetal monitor tracing showing late decelerations 3. Client sleeping between contractions 4. Blood pressure 150/90 5. Blood pressure 80/42

2,5

A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive.

3

A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Confirm fetal heart activity. 2. Evaluate the cervix. 3. Determine fetal presentation. 4. Amniotic fluid volume. 5. Fetal number

3,4,5

After inserting prostaglandin gel for cervical ripening, what should the nurse do? 1. Apply an internal fetal monitor. 2. Insert an indwelling catheter. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in a supine position with a right hip wedge.

4

A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the clients end-tidal carbon dioxide level. b. Document the findings in the clients chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

A

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

A

The nurse is administering intravenous acyclovir (Zovirax) to a patient with a viral infection. Which administration technique is correct? a. Infuse intravenous acyclovir slowly, over at least 1 hour. b. Infuse intravenous acyclovir by rapid bolus. c. Refrigerate intravenous acyclovir. d. Restrict oral fluids during intravenous acyclovir therapy.

A

The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

A

The nurse is monitoring a patient who is receiving muromonab-CD3 (Orthoclone OKT3) after an organ transplant. Which effect is possible with muromonab-CD3 therapy? a. Chest pain b. Hypotension c. Confusion d. Dysuria

A

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

A,B,C

During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.) a. Wheezing b. Diarrhea c. Shortness of breath d. Swelling of the tongue e. Itching f. Black, hairy tongue

A,C,D,E

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

B

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

B

Symptoms that may occur during the asymptomatic HIV infection stage include a. persistent fatigue, night sweats, thrush, and diarrhea. b. a short bout of flulike syndrome. c. pneumonia, lymphoma, Kaposi's sarcoma, and tuberculosis. d. hyperglycemia, heart arrhythmias, and loss of appetite.

B

.A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

B

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

B

Cancer therapy that uses radioactive isotopes is a. surgery. b. radiation. c. chemotherapy. d. x-rays.

B

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

B

The nurse is providing counseling to a woman who is HIV positive and has just discovered that she is pregnant. Which anti-HIV drug is given to HIV-infected pregnant women to prevent transmission of the virus to the infant? a. Acyclovir (Zovirax) b. Zidovudine (Retrovir) c. Ribavirin (Virazole) d. Foscarnet (Foscavir)

B

The nurse manager determines that four RNs, five LPN/LVNs, and two unlicensed assistive personnel (UAP) are required per shift to meet the needs of the patient population on the unit, according to acuity and census. The nurse manager is concerned with: a. assignments. b. staffing. c. output. d. productivity.

B

The nurse who is responsible for following the patient from admission through discharge or resolution of illness while working with a broad range of health care providers is called a: a. nurse manager. b. case manager. c. coordinator of patient-centered care delivery. d. team leader in team nursing care delivery.

B

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

B

The nutrient primarily responsible for maintaining tissue integrity and immunocompetence is/are a. carbohydrate. b. protein. c. vitamins. d. minerals.

B

To counteract the hypermetabolic state of cancer, it is important to increase the intake of a. protein. b. kilocalories. c. vitamins. d. fats.

B

When administering cyclosporine, the nurse notes that allopurinol is also ordered for the patient. What is a potential result of this drug interaction? a. Reduced adverse effects of the cyclosporine b. Increased levels of cyclosporine and toxicity c. Reduced uric acid levels d. Reduced nephrotoxic effects of cyclosporine

B

When monitoring a patient who is on immunosuppressant therapy with azathioprine (Imuran), the nurse will monitor which laboratory results? a. Serum potassium levels b. White blood cell (leukocyte) count c. Red blood cell count d. Serum albumin levels

B

Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? a. Assessing skin and mucous membranes b. Consistently using appropriate hand hygiene c. Monitoring daily white blood cell counts d. Teaching visitors not to visit if they are ill

B

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurses aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.

C

The nurse checks the patient's laboratory work prior to administering a dose of vancomycin (Vancocin) and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next? a. Administer the vancomycin as ordered. b. Hold the drug, and administer 4 hours later. c. Hold the drug, and notify the prescriber. d. Repeat the test to verify results.

C

The nurse is monitoring a patient who has been on antibiotic therapy for 2 weeks. Today the patient tells the nurse that he has had watery diarrhea since the day before and is having abdominal cramps. His oral temperature is 101° F (38.3° C). Based on these findings, which conclusion will the nurse draw? a. The patient's original infection has not responded to the antibiotic therapy. b. The patient is showing typical adverse effects of antibiotic therapy. c. The patient needs to be tested for Clostridium difficile infection. d. The patient will need to take a different antibiotic.

C

The nurse is monitoring for therapeutic results of antibiotic therapy in a patient with an infection. Which laboratory value would indicate therapeutic effectiveness of this therapy? a. Increased red blood cell count b. Increased hemoglobin level c. Decreased white blood cell count d. Decreased platelet count

C

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

C

The point at which a mutagen causes irreversible damage to DNA is referred to as a. neoplasms. b. promotion. c. initiation. d. Progression.

C

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C)

C

The primary goal in nutrition care of patients with cancer is to a. prevent further growth of the tumor. b. reduce nutrients that the tumor feeds on. c. prevent malnutrition. d. promote weight gain.

C

The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

C

When a patient is on aminoglycoside therapy, the nurse will monitor the patient for which indicators of potential toxicity? a. Fever b. White blood cell count of 8000 cells/mm3 c. Tinnitus and dizziness d. Decreased blood urea nitrogen (BUN) levels

C

A client is admitted with possible sepsis. Which action should the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.

D

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. Let me call the surgeon to see if you really need them. b. No, you have to use those for 24 hours after surgery. c. OK, we can remove them since you are stable now d. To prevent blood clots you need them a few more hours.

D

The nurse is administering a vancomycin (Vancocin) infusion. Which measure is appropriate for the nurse to implement in order to reduce complications that may occur with this drug's administration? a. Monitoring blood pressure for hypertension during the infusion b. Discontinuing the drug immediately if red man syndrome occurs c. Restricting fluids during vancomycin therapy d. Infusing the drug over at least 1 hour

D

The nurse is preparing to administer an injection of monoclonal antibodies. Which additional drug will the nurse administer to minimize adverse reactions to the monoclonal antibodies? a. A nonsteroidal anti-inflammatory drug b. A benzodiazepine c. An opioid pain reliever d. A corticosteroid

D

The nurse is preparing to use an antiseptic. Which statement is correct regarding how antiseptics differ from disinfectants? a. Antiseptics are used to sterilize surgical equipment. b. Disinfectants are used as preoperative skin preparation. c. Antiseptics are used only on living tissue to kill microorganisms. d. Disinfectants are used only on nonliving objects to destroy organisms.

D

The nurse is reviewing the medication orders for a patient who will be receiving gentamicin therapy. Which other medication or medication class, if ordered, would be a potential interaction concern? a. Calcium channel blockers b. Phenytoin c. Proton pump inhibitors d. Loop diuretics

D

The nurse working with clients who have autoimmune diseases understands that what component of cell- mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

D

The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? a. Colonization by host bacteria b. Gastrointestinal secretions c. Inflammatory processes d. Skin and mucous membranes

D

The nutrition care plan for AIDS patients is a. the same as for all patients. b. consistent throughout the course of the disease. c. based only on clinical observations and anthropometry. d. individualized and continually adjusted throughout the course of the disease.

D

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond? a. I can give your injections to you while you are here in the hospital. b. Everyone gets used to giving themselves injections. It really does not hurt. c. Your disease will not be managed properly if you refuse to administer the shots. d. Tell me what it is about the injections that are concerning you.

D

The nurse is reviewing the sputum culture results of a patient with pneumonia and notes that the patient has a gram-positive infection. Which generation of cephalosporin is most appropriate for this type of infection? a. First generation b. Second generation c. Third generation d. Fourth generation

A

The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery

1

The nurse is preparing a client for amniocentesis. Which statement would indicate that the client clearly understands the risks of an amniocentesis? 1. I might go into labor early. 2. It could produce a congenital defect in my baby. 3. Actually, there are no real risks to this procedure. 4. The test could stunt my babys growth.

1

The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first? 1. Perform Leopold maneuvers to determine fetal position. 2. Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (UC). 3. Dry the maternal abdomen before using the Doppler. 4. The diaphragm should be cooled before using the Doppler.

1

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond? 1. "These exercises help prevent pneumonia." 2. "The doctor ordered the exercises." 3. "All surgical clients must do these exercises." 4. "These exercises prevent thrombophlebitis."

1

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem

1

A laboring clients obstetrician has suggested amniotomy as a method for creating stronger contractions and facilitating birth. The client asks, What are the advantages of doing this? What should the nurse cite in response? 1. Contractions elicited are similar to those of spontaneous labor. 2. Amniotomy decreases the chances of a prolapsed cord. 3. Amniotomy reduces the pain of labor and makes it easier to manage. 4. The client will not need an episiotomy.

1

A nurse is checking the postpartum orders. The doctor has prescribed bed rest for 6-12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia? 1. Spinal 2. Pudendal 3. General 4. Epidural

1

A woman in active labor is given nalbuphine hydrochloride (Nubain) 14 mg IV for pain relief. Half an hour later, her respirations are at 8 per minute. The physician would likely order which medication for this client? 1. Narcan 2. Reglan 3. Benadryl 4. Vistaril

1

After administration of an epidural anesthetic to a client in active labor, it is most important to assess the mother immediately for which of the following? 1. Hypotension 2. Headache 3. Urinary retention 4. Bradycardia

1

After being in labor for several hours with no progress, a client is diagnosed with CPD (cephalopelvic disproportion), and must have a cesarean section. The client is worried that she will not be able to have any future children vaginally. After sharing this information with her care provider, the nurse would anticipate that the client would receive what type of incision? 1. Transverse 2. Infraumbilical midline 3. Classic 4. Vertical

1

An analgesic medication has been administered intramuscularly to a client in labor. How would the nurse evaluate if the medication was effective? 1. The client dozes between contractions. 2. The client is moaning during contractions. 3. The contractions decrease in intensity. 4. The contractions decrease in frequency.

1

At 32 weeks gestation, a woman is scheduled for a second non-stress test (following one she had at 28 weeks gestation). Which statement by the client would indicate an adequate understanding of this procedure? 1. I cant get up and walk around during the test. 2. Ill have an IV started before the test. 3. I can still smoke before the test. 4. I need to have a full bladder for this test.

1

During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest.

1

The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? 1. Woman at 7 cm, fetal heart tones auscultated every 90 minutes 2. Woman at 10 cm and pushing, external fetal monitor applied 3. Woman with meconium-stained fluid, internal fetal scalp electrode in use 4. Woman in preterm labor, external monitor in place

1

The client at 14 weeks gestation has undergone a transvaginal ultrasound to assess cervical length. The ultrasound revealed cervical funneling. How should the nurse explain these findings to the client? 1. Your cervix has become cone-shaped and more open at the end near the baby. 2. Your cervix is lengthened, and you will deliver your baby prematurely. 3. Your cervix is short, and has become wider at the end that extends into the vagina. 4. Your cervix was beginning to open but now is starting to close up again.

1

The client has been pushing for 3 hours, and the fetus is making a slow descent. The partner asks the nurse whether pushing for this long is normal. How should the nurse respond? 1. Your baby is taking a little longer than average, but is making progress. 2. First babies take a long time to be born. The next baby will be easier. 3. The birth would go faster if you had taken prenatal classes and practiced. 4. Every baby is different; there really are no norms for labor and birth.

1

The client tells the nurse that she has come to the hospital so that her babys position can be changed. The nurse would begin to organize the supplies needed to perform which procedure? 1. A version 2. An amniotomy 3. Leopold maneuvers 4. A ballottement

1

The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Assist the client to change position. 2. Apply oxygen to the client at 2 liters per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Determine the color of the leaking amniotic fluid.

1

The laboring clients fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters. 3. Prepare for imminent delivery. 4. Assist the client into Fowlers position.

1

The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? 1. Inform the maternal client that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal client on her side and administer oxygen.

1

The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color

1

The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis? 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask

1

The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase

1

The nurse is caring for a laboring client with thrombocytopenia. During labor, it is determined that the client requires a cesarean delivery. The nurse is preparing the client for surgery, and should instruct the client that the recommended method of anesthesia is which of the following? 1. General anesthesia 2. Epidural anesthesia 3. Spinal anesthesia 4. Regional anesthesia

1

The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively.

1

The nurse is inducing the labor of a client with severe preeclampsia. As labor progresses, fetal intolerance of labor develops. The induction medication is turned off, and the client is prepared for cesarean birth. Which statement should the nurse include in her preoperative teaching? 1. Because of your preeclampsia you are at higher risk for hypotension after an epidural anesthesia. 2. Because of your preeclampsia you might develop hypertension after a spinal anesthesia. 3. Because of your preeclampsia your baby might have decreased blood pressure after birth. 4. Because of your preeclampsia your husband will not be allowed into the operating room.

1

The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests

1

The nurse is responding to phone calls. Whose call should the nurse return first? 1. A client at 37 weeks gestation reports no fetal movement for 24 hours. 2. A client at 29 weeks gestation reports increased fetal movement. 3. A client at 32 weeks gestation reports decreased fetal movement X 2 days. 4. A client at 35 weeks gestation reports decreased fetal movement X 4 hours.

1

The nurse is reviewing charts of clients who underwent cesarean births by request in the last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased health care costs in clients undergoing cesarean birth by request? 1. Increased abnormal placenta implantation in subsequent pregnancies 2. Decreased use of general anesthesia with greater use of epidural anesthesia 3. Prolonged anemia, requiring blood transfusions every few months 4. Coordination of career projects of both partners leading to increased income

1

The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the clients chart requires immediate intervention? 1. Previous birth by cesarean 2. Frank breech ballotable 3. 37 weeks, complete breech 4. Failed ECV last week

1

The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed? 1. Because the scar on my belly goes down from my navel, I am not a candidate for a VBAC. 2. My first baby was in a breech position, so for this pregnancy, I can try a VBAC if the baby is head-down. 3. Because my hospital is so small and in a rural area, they wont let me attempt a VBAC. 4. The rate of complications from VBAC is lower than the rate of complications from a cesarean.

1

The nurse knows that a contraindication to the induction of labor is which of the following? 1. Placenta previa 2. Isoimmunization 3. Diabetes mellitus 4. Premature rupture of membranes

1

The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment (PPE) sparingly. 4. Wear gloves at all times.

1

The pregnant client and her partner are both 40 years old. The nurse is explaining the options of chorionic villus sampling (CVS) and amniocentesis for genetic testing. The nurse should correct the client if she makes which statement? 1. Amniocentesis results are available sooner than CVS results are. 2. CVS carries a higher risk of limb abnormalities. 3. Amniocentesis cannot detect a neural tube defect. 4. CVS is performed through my belly or my cervix.

1

The prenatal clinic nurse is explaining test results to a client who has had an assessment for fetal well-being. Which statement indicates that the client understands the test result? 1. The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby. 2. The reactive non-stress test means that my baby is not growing because of a lack of oxygen. 3. Because my contraction stress test was positive, we know that my baby will tolerate labor well. 4. My biophysical profile score of 6 points to everything being normal and healthy for my baby.

1

To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which type of medication? 1. Antacids 2. Tranquilizers 3. Antihypertensives 4. Anticonvulsants

1

What is the major adverse side effect of epidural anesthesia? 1. Maternal hypotension 2. Decrease in variability of the FHR 3. Vertigo 4. Decreased or absent respiratory movements

1

While irrigating a client's abdominal wound, the irrigate splashes into the nurse's nose and eyes. What should the nurse do? 1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline. 2. Begin HIV high-risk exposure prophylaxis within 24 hours. 3. Wash the areas with soap and water. 4. Have blood drawn for hepatitis B antibodies.

1

When general anesthesia is necessary for a cesarean delivery, what should the nurse be prepared to do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administer an antacid to the client. 2. Place a wedge under her thigh. 3. Apply cricoid pressure during anesthesia intubation. 4. Preoxygenate for 3-5 minutes before anesthesia. 5. Place a Foley catheter in the clients bladder.1

1,3,4,5

The nurse knows that the Bishop scoring system for cervical readiness includes which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal station 2. Fetal lie 3. Fetal presenting part 4. Cervical effacement 5. Cervical softness

1,4,5

A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client? a. How do you plan to pay for your treatments? b. How do you feel about yourself? c. What medications are you prescribed? d. What are you doing to prevent this from happening?

B

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention

1,2,3

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication. 5. Client is ambulating twice a day with assistance.

1,2,3

The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal dehydration 2. Maternal hyperthyroidism 3. Fetal hypoxia 4. Prematurity 5. Anesthesia or regional analgesia

1,2,3,4

The nurse is obtaining preoperative assessment data. What should be included in this assessment? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mother's maiden name

1,2,3,4

The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? Standard Text: Select all that apply. 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status

1,2,3,4

A prenatal client asks the nurse about conditions that would necessitate a cesarean delivery. The nurse explains that cesarean delivery generally is performed in the presence of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Complete placenta previa 2. Placental abruption 3. Umbilical cord prolapse 4. Precipitous labor 5. Failure to progress

1,2,3,5

During a visit to the obstetrician, a pregnant client questions the nurse about the potential need for an amniotomy. The nurse explains that an amniotomy is performed to do which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Stimulate the beginning of labor 2. Augment labor progression 3. Allow application of an internal fetal electrode 4. Allow application of an external fetal monitor 5. Allow insertion of an intrauterine pressure catheter

1,2,3,5

For what common side effects of epidural anesthesia should the nurse watch? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Elevated maternal temperature 2. Urinary retention 3. Nausea 4. Long-term back pain 5. Local itching

1,2,3,5

The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal hypotension 2. Prolonged umbilical cord compression 3. Fetal dysrhythmia 4. Central nervous system malformation 5. Late fetal asphyxia

1,2,3,5

Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Early fetalhypoxia 2. Prolonged fetal stimulation 3. Fetal anemia 4. Fetal sleep cycle 5. Infection

1,2,3,5

The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? Standard Text: Select all that apply. 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation.

1,2,4,5

Fetal factors that possibly indicate electronic fetal monitoring include which of the following? 1. Meconium passage 2. Multiple gestation 3. Preeclampsia 4. Grand multiparity 5. Decreased fetal movement

1,2,5

A client had an epidural inserted 2 hours ago. It is functioning well, the client is stable, and labor is progressing. Which parts of the nurses assessment have the highest priority? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess blood pressure every hour. 2. Assess the pulse rate every hour. 3. Palpate the bladder. 4. Auscultate the lungs. 5. Assess the reflexes.

1,3

Before performing Leopold maneuvers, what would the nurse do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Have the client empty her bladder. 2. Place the client in Trendelenburg position. 3. Have the client lie on her back with her feet on the bed and knees bent. 4. Turn the client to her left side. 5. Have the client lie flat with her ankles crossed.

1,3

The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a client's room. What action should the nurse take first for this puncture wound? 1. Complete an injury report. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water.

2

A client at 37 weeks gestation has a mildly elevated blood pressure. Her antenatal testing demonstrates three contractions in 10 minutes, no decelerations, and accelerations four times in 1 hour. What would this test be considered? 1. Positive non-stress test 2. Negative contraction stress test 3. Positive contraction stress test 4. Negative non-stress test

2

A client received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which problem during the fourth stage of labor? 1. Nausea 2. Bladder distention 3. Uterine atony 4. Hypertension

2

A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mother's breast milk with antibodies in it

2

A laboring client has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, what would the nurse expect to do? 1. Observe fetal heart rate variability 2. Hydrate the vascular system with 500-1000 mL of intravenous fluids 3. Place the client in the semi-Fowlers position 4. Teach the client appropriate breathing techniques

2

A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities

2

A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline be administered? 1. To provide analgesia 2. To relax the uterus 3. To induce labor 4. To prevent hemorrhage

2

A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurses teaching? 1. The most important part of fetal heart monitoring is the absence of variable decelerations. 2. The most important part of fetal heart monitoring is the presence of variability. 3. The most important part of fetal heart monitoring is the fetal heart rate baseline. 4. The most important part of fetal heart monitoring is the depth of decelerations.

2

Narcotic analgesia is administered to a laboring client at 10:00 a.m. The infant is delivered at 12:30 p.m. What would the nurse anticipate that the narcotic analgesia could do? 1. Be used in place of preoperative sedation 2. Result in neonatal respiratory depression 3. Prevent the need for anesthesia with an episiotomy 4. Enhance uterine contractions

2

Of all the clients who have been scheduled to have a biophysical profile, the nurse should check with the physician and clarify the order for which client? 1. A gravida with intrauterine growth restriction 2. A gravida with mild hypotension of pregnancy 3. A gravida who is postterm 4. A gravida who complains of decreased fetal movement for 2 days

2

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

B

The client at 39 weeks gestation is undergoing a cesarean birth due to breech presentation. General anesthesia is being used. Which situation requires immediate intervention? 1. The babys hands and feet are blue at 1 minute after birth. 2. The fetal heart rate is 70 prior to making the skin incision. 3. Clear fluid is obtained from the babys oropharynx. 4. The neonate cries prior to delivery of the body.

2

The client has been pushing for two hours, and is exhausted. The fetal head is visible between contractions. The physician informs the client that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. A small cup will be put onto the babys head, and a gentle suction will be applied. 2. I can stop pushing and just rest if the vacuum extractor is used. 3. The babys head might have some swelling from the vacuum cup. 4. The vacuum will be applied for a total of ten minutes or less.

2

The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The clients partner asks why the nurse did that. What is the best response by the nurse? 1. I stimulated the top of the fetuss head to wake him up a little. 2. I stimulated the top of the fetuss head to try to get his heart rate to accelerate. 3. I stimulated the top of the fetuss head to calm the fetus down before birth. 4. I stimulated the top of the fetuss head to find out whether he is in distress.

2

The client presents for cervical ripening in anticipation of labor induction tomorrow. What should the nurse include in her plan of care for this client? 1. Apply an internal fetal monitor. 2. Monitor the client using electronic fetal monitoring. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in a upright, sitting position.

2

The laboring client brought a written birth plan indicating that she wanted to avoid pain medications and an epidural. She is now at 6 cm and states, I cant stand this anymore! I need something for pain! How will an epidural affect my baby? What is the nurses best response? 1. The narcotic in the epidural will make both you and the baby sleepy. 2. It is unlikely that an epidural will decrease your babys heart rate. 3. Epidurals tend to cause low blood pressure in babies after birth. 4. I cant get you an epidural, because of your birth plan.

2

The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The physician requests that a vacuum extractor be used to facilitate the birth. The client first states that she wants the birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth? 1. Elation, euphoria, and talkativeness 2. A sense of failure and loss 3. Questions about whether or not to circumcise 4. Uncertainty surrounding the babys name

2

The need for forceps has been determined. The clients cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurse anticipate? 1. Input 2. Low 3. Mid 4. Outlet

2

The nurse anticipates that the physician will most likely order a cervicovaginal fetal fibronectin test for which client? 1. The client at 34 weeks gestation with gestational diabetes 2. The client at 32 weeks gestation with regular uterine contractions 3. The client at 37 weeks multi-fetal gestation 4. The client at 20 weeks gestation with ruptured amniotic membranes

2

The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin

2

The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place

2

The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment.

2

The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes

2

The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls

2

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? 1. Cut the needle off a syringe after using it to give a client an injection. 2. Dispose of blood-contaminated materials in a biohazard container. 3. Gloves should not be worn for client care unless body fluids are seen. 4. Wear a mask when in direct contact with all clients.

2

The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the client's blood pressure. 4. Clean the stockings.

2

The nurse is reviewing amniocentesis results. Which of the following would indicate that client care was appropriate? 1. The client who is Rh-positive received Rh immune globulin after the amniocentesis. 2. The client was monitored for 30 minutes after completion of the test. 3. The client began vaginal spotting before leaving for home after the test. 4. The client identified that she takes insulin before each meal and at bedtime.

2

The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring client who will have a forceps delivery. Which action or assessment finding requires intervention? 1. Regional anesthesia is administered via pudendal block. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. The clients bladder is emptied using a straight catheter.

2

The nurse is working with a pregnant adolescent. The client asks the nurse how the babys condition is determined during labor. The nurses best response is that during labor, the nurse will do which of the following? 1. Check the clients cervix by doing a pelvic exam every 2 hours. 2. Assess the fetuss heart rate with an electronic fetal monitor. 3. Look at the color and amount of bloody show that the client has. 4. Verify that the clients contractions are strong but not too close together.

2

The physician has determined the need for forceps. The nurse should explain to the client that the use of forceps is indicated because of which of the following? 1. Her support person is exhausted 2. Premature placental separation 3. To shorten the first stage of labor 4. To prevent fetal distress

2

The physicians/CNM opts to use a vacuum extractor for a delivery. What does the nurse understand? 1. There is little risk with vacuum extraction devices. 2. There should be further fetal descent with the first two pop-offs. 3. Traction is applied between contractions. 4. The woman often feels increased discomfort during the procedure.

2

What type of forceps are designed to be used with a breech presentation? 1. Midforceps 2. Piper 3. Low 4. High

2

Which of the following tests provides information about the fetal number? 1. Amniocentesis 2. Standard second-trimester sonogram 3. Beta hCG 4. Maternal serum alpha-fetoprotein

2

he nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the clients psychosocial status? 1. How did you decide to have your baby at this hospital? 2. Who will be your labor support person? 3. Have you chosen names for your baby yet? 4. What feeding method will you use for your baby?

2

A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition? a. Decreased blood pressure b. Increased pulse c. Decreased respiratory rate d. Increased urine output

B

Under which circumstances would the nurse remove prostaglandin from the clients cervix? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Contractions every 5 minutes 2. Nausea and vomiting 3. Uterine tachysystole 4. Cardiac tachysystole 5. Baseline fetal heart rate of 140-148

2,3,4

A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? Standard Text: Select all that apply. 1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group.

2,4

In which clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Placental abruption 2. Meconium-stained fluid 3. Polyhydramnios 4. Variable decelerations 5. Early decelerations

2,4

A client at 40 weeks gestation is to undergo stripping of the membranes. The nurse provides the client with information about the procedure. Which information is accurate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Intravenous administration of oxytocin will be used to initiate contractions. 2. The physician/CNM will insert a gloved finger into the cervical os and rotate the finger 360 degrees. 3. Stripping of the membranes will not cause discomfort, and is usually effective. 4. Labor should begin within 24-48 hours after the procedure. 5. Uterine contractions, cramping, and a bloody discharge can occur after the procedure.

2,4,5

Amniotomy as a method of labor induction has which of the following advantages? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The danger of a prolapsed cord is decreased. 2. There is usually no risk of hypertonus or rupture of the uterus. 3. The intervention can cause a decrease in pain. 4. The color and composition of amniotic fluid can be evaluated. 5. The contractions elicited are similar to those of spontaneous labor.

2,4,5

The nurse is monitoring a client who is receiving an amnioinfusion. Which assessments must the nurse perform to prevent a serious complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Color of amniotic fluid 2. Maternal blood pressure 3. Cervical effacement 4. Uterine resting tone 5. Fluid leaking from the vagina

2,4,5

The nurse is planning to remove the sutures from a client's surgical wound. What should the nurse do before removing the sutures? Standard Text: Select all that apply. 1. Apply clean gloves. 2. Verify the order for suture removal. 3. Ambulate the client to the bathroom. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision.

2,4,5

The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls

3

A client dilated to 5 cm has just received an epidural for pain. She complains of feeling lightheaded and dizzy within 10 minutes after the procedure. Her blood pressure was 120/80 before the procedure and is now 80/52. In addition to the bolus of fluids she has been given, which medication is preferred to increase her BP? 1. Epinephrine 2. Terbutaline 3. Ephedrine 4. Epifoam

3

A client is consulting a certified nurse-midwife because she is hoping for a vaginal birth after cesarean (VBAC) with this pregnancy. Which statement indicates that the client requires more information about VBAC? 1. I can try a vaginal birth because my uterine incision is a low segment transverse incision. 2. The vertical scar on my skin doesnt mean that the scar on my uterus goes in the same direction. 3. There is about a 90% chance of giving birth vaginally after a cesarean. 4. Because my hospital has a surgery staff on call 24 hours a day, I can try a VBAC there.

3

A client needs to be placed in contact isolation. What items should the nurse ensure are included in this client's room? 1. Cabinet stocked with gloves and gowns 2. Cards and records 3. Paper towels, sink, and blood pressure cuff 4. Sign on the door

3

A laboring client asks the nurse, Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor? The nurse would accurately explain that the best rationale for using an IUPC is which of the following? 1. The IUPC can be used throughout the birth process. 2. A tocodynamometer is invasive. 3. The IUPC provides more accurate data than does the tocodynamometer. 4. The tocodynamometer can be used only after the cervix is dilated 2 cm.

3

A laboring clients obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed? 1. Maternal temperature, BP, and pulse 2. Estimation of fetal birth weight 3. Fetal presentation, position, and station 4. Biparietal diameter

3

After nalbuphine hydrochloride (Nubain) is administered, labor progresses rapidly, and the baby is born less than 1 hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn? 1. Fentanyl (Sublimaze) 2. Butorphanol tartrate (Stadol) 3. Naloxone (Narcan) 4. Pentobarbital (Nembutal)

3

After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? 1. Increase the mothers oxygen rate. 2. Turn the mother to the left lateral position. 3. Prepare the mother for a higher-risk delivery. 4. Increase the intravenous infusion rate.

3

During a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test, and last 20 seconds each. The nurse realizes these results will be interpreted as which of the following? 1. A negative test 2. A reactive test 3. A nonreactive test 4. An equivocal test

3

Induction of labor is planned for a 31-year-old client at 39 weeks due to insulin-dependent diabetes. Which nursing action is most important? 1. Administer 100 mcg of misoprostol (Cytotec) vaginally every 2 hours. 2. Place dinoprostone (Prepidil) vaginal gel and ambulate client for 1 hour. 3. Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec). 4. Prepare to induce labor after administering a tap water enema.

3

Major perineal trauma (extension to or through the anal sphincter) is more likely to occur if what type of episiotomy is performed? 1. Mediolateral 2. Episiorrhaphy 3. Midline 4. Medical

3

Persistent early decelerations are noted. What would the nurses first action be? 1. Turn the mother on her left side and give oxygen. 2. Check for prolapsed cord. 3. Do nothing. This is a benign pattern. 4. Prepare for immediate forceps or cesarean delivery.

3

The client demonstrates understanding of the implications for future pregnancies secondary to her classic uterine incision when she states which of the following? 1. The next time I have a baby, I can try to deliver vaginally. 2. The risk of rupturing my uterus is too high for me to have any more babies. 3. Every time I have a baby, I will have to have a cesarean delivery. 4. I can only have one more baby.

3

The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected and normal? 1. The head is delivered after eight pop-offs during contractions. 2. A cephalohematoma is present on the fetal scalp. 3. The location of the vacuum is apparent on the fetal scalp after birth. 4. Positive pressure is applied by the vacuum extraction during contractions.

3

The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse? 1. Ill get you one right away. 2. You only need to use one ice pack. 3. You need to leave it off for at least 20 minutes and then reapply. 4. Ill bring you an extra so that you can change it when you are ready.

3

The client requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts a mediolateral episiotomy. After delivery, the client asks the nurse to describe the episiotomy. What does the nurse respond? 1. The episiotomy goes straight back toward your rectum. 2. The episiotomy is from your vagina toward the urethra. 3. The episiotomy is cut diagonally away from your vagina. 4. The episiotomy extends from your vagina into your rectum.

3

The client with a normal pregnancy had an emergency cesarean birth under general anesthesia 2 hours ago. The client now has a respiratory rate of 30, pale blue nail beds, a pulse rate of 110, and a temperature of 102.6F, and is complaining of chest pain. The nurse understands that the client most likely is experiencing which of the following? 1. Pulmonary embolus 2. Pneumococcal pneumonia 3. Pneumonitis 4. Gastroesophageal reflux disease

3

The client with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the client understands the need for this additional antepartal fetal surveillance? 1. After the ultrasound, my partner and I will decide how to decorate the nursery. 2. During the ultrasound we will see which of us the baby looks like most. 3. The ultrasound will show whether there are abnormalities with the babys spine. 4. The blood test wasnt run correctly, and now we need to have the sonogram.

3

The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? 1. Early decelerations with each contraction 2. Variable decelerations that recover to the baseline 3. Late decelerations with minimal variability 4. Accelerations

3

The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? 1. The monitor is necessary so we can see how your labor is progressing. 2. The monitor will prevent complications from the meconium in your fluid. 3. The monitor helps us to see how the baby is tolerating labor. 4. The monitor can be removed, and oxygen given instead.

3

The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube. 3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents.

3

The nurse has just palpated contractions and compares the consistency to that of the forehead to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? 1. Mild 2. Moderate 3. Strong 4. Weak

3

The nurse is admitting a client to the labor and delivery unit. Which aspect of the clients history requires notifying the physician? 1. Blood pressure 120/88 2. Father a carrier of sickle-cell trait 3. Dark red vaginal bleeding 4. History of domestic abuse

3

The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? 1. Moderate variability 2. Early decelerations 3. Late decelerations 4. Accelerations

3

The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? 1. Late decelerations 2. Early decelerations 3. Accelerations 4. Fetal dysrhythmia

3

The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head

3

The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion.

3

The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the client's room. 3. Wash hands. 4. Wear a mask for all client care.

3

The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching has been effective? 1. If the ultrasound is normal, it means my baby has no abnormalities. 2. The nuchal translucency measurement will diagnose Down syndrome. 3. I might be able to see who the baby looks like with the ultrasound. 4. Measuring the length of my cervix will determine whether I will deliver early.

3

The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound? 1. Adjust the diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify the physician of any edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide.

3

The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to 1. sterilize the skin. 2. assess the surgical site before surgery. 3. reduce the risk of postoperative wound infection. 4. clean any moles the client may have.

3

The nurse is preparing to remove soiled gloves. What action should the nurse take first? 1. Drop the gloves into the appropriate waste receptacle. 2. Ease the fingers into the gloves. 3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove.

3

The nurse is providing preoperative teaching to a client for whom a cesarean birth under general anesthesia is scheduled for the next day. Which statement by the client indicates that she requires additional information? 1. General anesthesia can be accomplished with inhaled gases. 2. General anesthesia usually involves administering medication into my IV. 3. General anesthesia will provide good pain relief after the birth. 4. General anesthesia takes effect faster than an epidural.

3

The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid means which of the following? 1. Fetal lungs are still immature. 2. The fetus has a congenital anomaly. 3. Fetal lungs are mature. 4. The fetus is small for gestational age.

3

The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? 1. The client is assisted into supine position, and the position of the fetus is assessed. 2. The upper portion of the uterus is palpated, then the middle section. 3. After determining where the back is located, the cervix is assessed. 4. Following voiding, the clients abdomen is palpated from top to bottom.

3

Two hours after an epidural infusion has begun, a client complains of itching on her face and neck. What should the nurse do? 1. Remove the epidural catheter and apply a Band-Aid to the injection site. 2. Offer the client a cool cloth and let her know the itching is temporary. 3. Recognize that this is a common side effect, and follow protocol for administration of Benadryl. 4. Call the anesthesia care provider to re-dose the epidural catheter.

3

When assisting with a transabdominal sampling, which of the following would the nurse do? 1. Obtain preliminary urinary samples. 2. Have the woman empty her bladder before the test begins. 3. Assist the woman into a supine position on the examining table. 4. Instruct the woman to eat a fat-free meal 2 hours before the scheduled test time.

3

Which of the following is a major side effect of butorphanol tartrate (Stadol)? 1. Blurred vision 2. Agitation 3. Feelings of dysphoria 4. Drowsiness

3

Which of the following tests has become a widely accepted method of evaluating fetal status? 1. Contraction stress test (CST) 2. MSAFP test 3. Non-stress test (NST) 4. Nuchal translucency test

3

A woman is scheduled to have an external version for a breech presentation. The nurse carefully reviews the clients chart for contraindications to this procedure, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Station -2 2. 38 weeks gestation 3. Abnormal fetal heart rate and tracing 4. Previous cesarean section 5. Rupture of membranes

3,4,5

Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client? 1. 28-year-old with history of rheumatic heart disease 2. 18-year-old with exposure to HIV 3. 20-year-old with a history of preterm labor 4. 35-year-old with a child with spina bifida

4

In the operating room, a client is being prepped for a cesarean delivery. The doctor is present. What is the last assessment the nurse should make just before the client is draped for surgery? 1. Maternal temperature 2. Maternal urine output 3. Vaginal exam 4. Fetal heart tones

4

Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client in which position? 1. On her right side in the center of the bed with her back curved 2. Lying prone with a pillow under her chest 3. On her left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed

4

The client is having fetal heart rate decelerations. An amnioinfusion has been ordered for the client to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is which of the following? 1. Early decelerations 2. Moderate decelerations 3. Late decelerations 4. Variable decelerations

4

A client has just been admitted for labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The client wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the client understands which of the following? 1. In order to respect her wishes, no medication will be given. 2. Pain relief will allow a more enjoyable birth experience. 3. The use of medications allows the client to rest and be less fatigued. 4. Maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.

4

A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest? 1. That a mild analgesic be administered 2. An epidural 3. A local anesthetic block 4. Nonpharmacologic methods of pain relief

4

A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation? 1. The fetal heart rate decelerates when three contractions occur within a 10-minute period. 2. The fetal heart rate accelerates when contractions last up to 60 seconds. 3. There are more than five fetal movements in a 10-minute period. 4. There are more than three uterine contractions in a 6-minute period.

4

A woman at 28 weeks gestation is asked to keep a fetal activity record and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for more than 30 minutes. Which of the following would be the nurses most appropriate initial comment? 1. You need to come to the clinic right away for further evaluation. 2. Have you been smoking? 3. When did you eat last? 4. Your baby might be asleep.

4

A woman is in labor. The fetus is in vertex position. When the clients membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? 1. Change the clients position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring.

4

After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? 1. Breech presentation 2. Uteroplacental insufficiency 3. Compression of the fetal head 4. Umbilical cord compression

4

An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client

4

During a maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in what quadrant? 1. Right upper quadrant 2. Left upper quadrant 3. Right lower quadrant 4. Left lower quadrant

4

The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet.

4

The nurse has presented a session on pain relief options to a prenatal class. Which statement indicates that additional teaching is needed? 1. An epidural can be continuous or can be given in one dose. 2. A spinal is usually used for a cesarean birth. 3. Pudendal blocks are effective when a vacuum is needed. 4. Local anesthetics provide good labor pain relief.

4

The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap.

4

The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement by the client indicates that further information is required? 1. Because I have a midline episiotomy, I should keep my perineum clean. 2. I can use an ice pack to relieve some the pain from the episiotomy. 3. I can take ibuprofen (Motrin) when my perineum starts to hurt. 4. The tear I have through my rectum is unrelated to my episiotomy.

4

The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile object to a sterile field with a clean gloved hand

4

The nurse is explaining induction of labor to a client. The client asks what the indications for labor induction are. Which of the following should the nurse include when answering the client? 1. Suspected placenta previa 2. Breech presentation 3. Prolapsed umbilical cord 4. Hypertension

4

The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation

4

The nurse is preparing to assess a laboring client who has just arrived in the labor and birth unit. Which statement by the client indicates that additional education is needed? 1. You are going to do a vaginal exam to see how dilated my cervix is. 2. The reason for a pelvic exam is to determine how low in the pelvis my baby is. 3. When you check my cervix, you will find out how thinned out it is. 4. After you assess my pelvis, you will be able to tell when I will deliver.

4

The nurse is preparing to leave a client's isolation room. Which action should the nurse take first when removing a grossly soiled gown? 1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first.

4

The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only.

4

The nurse is returning phone calls from clients. Which client does the nurse anticipate would not require a serum beta hCG? 1. A client with a risk of ectopic pregnancy 2. A client with spotting during pregnancy 3. A client with previous pelvic inflammatory disease 4. A client with a previous history of twins

4

The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient

4

The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy 3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy

4

The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? 1. Disinfecting an item before adding it to a sterile field 2. Allowing sterile gloved hands to fall below the waist 3. Suctioning the oral cavity of an unconscious client 4. Touching only the inside surface of the first glove while pulling it onto the hand

4

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications 2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment

4

The nurse is working in an outpatient clinic. Which clients indications most warrant fetal monitoring in the third trimester? 1. Gravida 4, para 3, 39 weeks, with a history of one spontaneous abortion at 8 weeks 2. Gravida 1, para 0, 40 weeks, with a history of endometriosis and a prior appendectomy 3. Gravida 3, para 2, with a history of gestational diabetes controlled by diet 4. Gravida 2, para 1, 36 weeks, with a history of history of preterm labor or cervical insufficiency

4

The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the client's risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours. 3. Monitor intake and output every 2 hours. 4. Provide for early ambulation.

4

Toward the end of the first stage of labor, a pudendal block is administered transvaginally. What will the nurse anticipate the clients care will include? 1. Monitoring for hypotension every 15 minutes 2. Monitoring FHR every 15 minutes 3. Monitoring for bladder distention 4. No additional assessments

4

During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The clients partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Uterine contraction pattern 2. Fetal position 3. Presence of the mucous plug 4. Cervical dilation and effacement 5. Presenting part

4,5

The client at 24 weeks gestation is experiencing painless vaginal bleeding after intercourse. The physician has ordered a transvaginal ultrasound examination. Which statements by the client indicate an understanding of why this exam has been requested? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. This ultrasound will show the babys gender. 2. This ultrasound might cause the miscarriage of my baby. 3. This ultrasound carries a risk of creating a uterine infection. 4. This ultrasound can determine the location of my placenta. 5. This ultrasound might detect whether the placenta is detaching prematurely.

4,5

A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency? a. Increased urine output b. Vasoconstriction c. Blood glucose of 98 mg/dL d. Serum sodium of 144 mEq/L

A

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

A

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the- counter antihistamines. What response by the nurse is most appropriate? a. Antihistamines do not help poison ivy. b. There are different antihistamines to try. c. You should be seen in the clinic right away. d. You will need to take some IV steroids.

A

A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Elevate the arm above the level of the heart. b. Order a fan to help cool the client if feverish. c. Place cool, wet cloths on top of the wound. d. Take the clients temperature every 4 hours.

A

A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best? a. Assess the client frequently for worsening of his or her condition. b. Delegate comfort measures to unlicensed assistive personnel. c. Ensure the client is placed on Contact Precautions. d. Restrict visitors to the immediate family only.

A

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

A

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

A

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. B. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

A

A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.

A

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? a. Consult with the provider about obtaining stool cultures. b. Delegate frequent perianal care to unlicensed assistive personnel. c. Place the client on NPO status until the diarrhea resolves. d. Request a prescription for an anti-diarrheal medication.

A

The nurse is providing teaching to a patient taking an oral tetracycline antibiotic. Which statement by the nurse is correct? a. "Avoid direct sunlight and tanning beds while on this medication." b. "Milk and cheese products result in increased levels of tetracycline." c. "Antacids taken with the medication help to reduce gastrointestinal distress." d. "Take the medication until you are feeling better."

A

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

A

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

A

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed d. You have a higher risk of developing cancer.

A

A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. It increases the elimination of T lymphocytes from circulation. b. It inhibits cytokine production in most lymphocytes. c. It prevents DNA synthesis, stopping cell division in activated lymphocytes. d. It prevents the activation of the lymphocytes responsible for rejection.

A

A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the clients lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer?(Click the media button to hear the audio clip.) a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

A

A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.

A

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

A

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

A

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? a. Ensure that the radiology department is aware of the isolation precautions. b. Plan to travel with the client to ensure appropriate precautions are used. c. No special precautions are needed when this client leaves the unit.' d. Notify the physician that the client cannot leave the room for the CT scan.

A

A nurse assesses a client diagnosed with adrenal hypofunction. Which client statement should the nurse correlate with this diagnosis?a. I have a terrible craving for potato chips. b. I cannot seem to drink enough water. c. I no longer have an appetite for anything. d. I get hungry even after eating a meal.

A

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the clients chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

A

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the clients clinical manifestations have not changed. Which action should the nurse take next? A. Administer another half-cup of orange juice. B. Administer a half-ampule of dextrose 50% intravenously. C. Administer 10 units of regular insulin subcutaneously. D. Administer 1 mg of glucagon intramuscularly.

A

A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider? a. Heart rate of 50 beats/min b. Respiratory rate of 18 breaths/min c. Oxygenation saturation of 92% d. Blood pressure of 144/69 mm Hg

A

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? A. Administer 1 mg of intramuscular glucagon. B. Encourage the client to drink orange juice. C. Insert a new intravenous access line. D. Administer 25 mL dextrose 50% (D50) IV push.

A

A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond? A. Your risk of diabetes is higher than the general population, but it may not occur. B. No genetic risk is associated with the development of type 1 diabetes mellitus. C. The risk for becoming a diabetic is 50% because of how it is inherited. D. Female children do not inherit diabetes mellitus, but male children will.

A

A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next? a. Ask the UAP if he washed his hands afterward. b. Have the UAP fill out an incident report. c. Ask the laboratory if the container has preservative in it. d. Send the UAP to Employee Health right away.

A

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond? A. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. B. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light. C. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes. D. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.

A

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP? a. Note the time of the clients first void and collect urine for 24 hours. b. Add the preservative to the container at the end of the test. c. Start the collection by saving the first urine of the morning. d. It is okay if one urine sample during the 24 hours is not collected.

A

A nurse groups patients with criteria such as "high risk for falls," "infection protocols," and "special communication needs" to determine the mix and number of staff needed on a telemetry unit. The nurse is using: a. a patient classification system to determine safe staffing levels. b. diagnostic-related groups for Medicare billing. c. case management to coordinate care.

A

A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I dont need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes.

A

A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best? a. Assess the client for more specific signs b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

A

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin (Vancocin). b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.

A

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

A

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

A

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

A

A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, Why do I need to collect urine for 24 hours instead of providing a random specimen? How should the nurse respond? a. This test will assess for a hormone secreted on a circadian rhythm. b. The hormone is diluted in urine; therefore, we need a large volume. c. We are assessing when the hormone is secreted in large amounts. d. To collect the correct hormone, you need to urinate multiple times.

A

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications? A. Maintain tight glycemic control and prevent hyperglycemia. B. Restrict your fluid intake to no more than 2 liters a day. C. Prevent hypoglycemia by eating a bedtime snack. D. Limit your intake of protein to prevent ketoacidosis.

A

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.

A

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. Auditing staff members hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods

A

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

A

A patient is about to undergo a kidney transplant. She will be given an immunosuppressant drug before, during, and after surgery to minimize organ rejection. During the preoperative teaching session, which information will the nurse include about the medication therapy? a. Several days before the surgery, the medication will be administered orally. b. The oral doses need to be taken 1 hour before meals to maximize absorption. c. Mix the oral liquid with juice in a disposable Styrofoam cup just before administration. d. Intramuscular injections of the medication will be needed for several days preceding surgery.

A

A patient is receiving aminoglycoside therapy and will be receiving a beta-lactam antibiotic as well. The patient asks why two antibiotics have been ordered. What is the nurse's best response? a. "The combined effect of both antibiotics is greater than each of them alone." b. "One antibiotic is not strong enough to fight the infection." c. "We have not yet isolated the bacteria, so the two antibiotics are given to cover a wide range of microorganisms." d. "We can give a reduced amount of each one if we give them together."

A

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

A

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg

A

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

A

A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? A. Document the finding in the clients chart. B. Administer a bolus of regular insulin IV. C. Call the surgeon to cancel the procedure. D. Draw blood gases to assess the metabolic state.

A

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. A rapid heart rate requires more effort by the heart. b. Anesthesia has bad effects if the client is tachycardic c. The client may have an undiagnosed heart condition. d. When the heart rate goes up, the blood pressure does too.

A

A student nurse asks why brushing clients teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best? a. It mechanically removes biofilm on teeth. b. Its easier to clean all surfaces with a brush. c. Oral care is important to all our clients. d. Toothbrushes last longer than oral swabs.

A

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional education? A. If I develop an infection, I should stop taking my corticosteroid. B. If I have pain over the transplant site, I will call the surgeon immediately. C. I should avoid people who are ill or who have an infection. D. I should take my cyclosporine exactly the way I was taught.

A

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.

A

An HIV-positive patient should be referred to the clinical dietitian on the AIDS team a. at the first contact with a health professional. b. at stage 2 (AIDS-related complex). c. at stage 3 (final stage of AIDS). d. when the patient has nutrition-related problems.

A

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? A. Increased rate and depth of respiration B. Extremity tremors followed by seizure activity C. Oral temperature of 102 F (38.9 C) D. Severe orthostatic hypotension

A

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

A

During drug therapy for pneumonia, a female patient develops a vaginal superinfection. The nurse explains that this infection is caused by: a. large doses of antibiotics that kill normal flora. b. the infection spreading from her lungs to the new site of infection. c. resistance of the pneumonia-causing bacteria to the drugs. d. an allergic reaction to the antibiotics.

A

Given a functional gastrointestinal tract, the preferred method of feeding a patient with cancer is a. normal oral intake. b. a liquid formula diet. c. tube feeding. d. total parenteral feeding.

A

Nutrition support is a vital care component throughout the progression of HIV infection because of its role in a. controlling involuntary weight loss and tissue wasting. b. maintaining cardiac function. c. preventing the spread of the HIV virus. d. preventing anemia and constipation.

A

Of the following, a side effect of protrease inhibitors is a. hyperglycemia. b. hypoglycemia. c. yachycardia. d. stroke.

A

Ordinarily the cell operates in an orderly fashion under the influence of the a. genetic code. b. outside environment. c. endoplasmic reticulum. d. nutrients taken into the cell.

A

Patients who receive chemotherapy drugs often develop anemia because the drugs a. damage the bone marrow. b. prevent iron absorption. c. interfere with folate metabolism. d. destroy hemoglobin.

A

Protease inhibitors work by a. inhibiting the enzyme protease. b. preventing reverse transcriptase. c. binding to HIV. d. enhancing the enzyme lipase.

A

The cells that activate the phagocytes are the a. T cells. b. B cells. c. lymphocytes. d. antigens.

A

The cellular component of the immune system that is derived from the thymus is the a. T cell. b. cell. c. phagocyte. d. lymphocyte.

A

The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

A

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client

A

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

A

When reviewing the medication orders for a patient who is taking penicillin, the nurse notes that the patient is also taking the oral anticoagulant warfarin (Coumadin). What possible effect may occur as the result of an interaction between these drugs? a. The penicillin will cause an enhanced anticoagulant effect of the warfarin. b. The penicillin will cause the anticoagulant effect of the warfarin to decrease. c. The warfarin will reduce the anti-infective action of the penicillin. d. The warfarin will increase the effectiveness of the penicillin.

A

Which of the following describes a disadvantage of abdominal radiation? a. The structure and function of the bowel may be adversely affected. b. The radiation can be dispersed to all the abdominal organs once it passes into the cavity. c. It is hard to pinpoint the precise area to target the radiation. d. There are no disadvantages.

A

Which statement made by the client indicates a need for additional teaching? A. The lower abdomen is the best location because it is closest to the pancreas. B. I can reach my thigh the best, so I will use the different areas of my thighs. C. By rotating the sites in one area, my chance of having a reaction is decreased. D. Changing injection sites from the thigh to the arm will change absorption rates.

A

he nurse manager is planning staffing levels and realizes that the first step is to: a. know the intensity of care needed by patients according to physical and psychosocial factors. b. examine the educational level of the staff. c. assess the skill level of caregivers. d. review the budget to determine the financial consequences of past staffing patterns.

A

rNurses on a unit provide personal hygiene, administer medications, educate the patient and family about treatments, and provide emotional support. These nurses provide patient care based on which nursing delivery system? a. Total patient care b. Partnership nursing c. Team nursing d. Functional nursing

A

A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best? a. Assess the clients gag reflex. b. Begin providing discharge instructions. c. Document findings and continue to monitor. d. Increase oxygen and notify the provider.

C

A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a clients bed linens. What action by the UAP requires intervention by the nurse? a. Not using gloves while combing the clients hair b. Rinsing the clients commode pan after use c. Shaking dirty linens and placing them on the floor d. Wearing gloves when providing perianal care

C

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? A. Urine specific gravity of 1.033 B. Presence of protein in the urine C. Elevated capillary blood glucose level D. Presence of ketone bodies in the urine

B

.A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond? A.Glucose is the only fuel used by the body to produce the energy that it needs. B. Your brain needs a constant supply of glucose because it cannot store it. C. Without a minimum level of glucose, your body does not make red blood cells. D. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.

B

A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self- management by teaching what principle of medical management? a. Infusions will be scheduled every 3 to 4 weeks. b. Treatment is aimed at treating specific infections. c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions.

B

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the clients vital signs. d. Teach relaxation techniques.

B

A client has been placed on Contact Precautions. The clients family is very afraid to visit for fear of being contaminated by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Inform them that the infection is the issue, not the client. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.

B

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

B

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the clients bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.

B

A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first? a. Obtain cultures of the lesions. b. Place the client on Airborne Precautions. c. Prepare to administer antibiotics. d. Provide comfort measures for the rash.

B

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best? a. Call a time-out to discuss sterile procedure and scrub technique .b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeons actions to the charge nurse and unit manager.

B

A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

B

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the clients anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

B

A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest? a. Frequent eyedrops b. Home humidifier c. Strong moisturizer d. Tear duct plugs

B

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

B

A hospital converts to a system of care delivery in which RNs, LPNs, and unlicensed assistive personnel (UAP) are responsible for implementing a specific task, such as medication administration or personal hygiene, for the entire nursing unit. This type of delivery system is: a. total patient care. b. functional nursing. c. team nursing. d. primary nursing.

B

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the clients blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

B

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

C

A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing. How should the nurse respond? A. Following the drug regimen more closely would have prevented this. B. One acute rejection episode does not mean that you will lose the new organs. C. Dialysis is a viable treatment option for you and may save your life. D. Since you are on the national registry, you can receive a second transplantation.

B

A nurse cares for a client who is prescribed a drug that blocks a hormones receptor site. Which therapeutic effect should the nurse expect? a. Greater hormone metabolism b. Decreased hormone activity c. Increased hormone activity d. Unchanged hormone response

B

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? A. Assess for pain or burning with urination. B. Review the clients liver function study results. C. Instruct the client to increase water intake. D. Test a sample of urine for occult blood.

B

A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond? A. You need to start with multiple injections until you become more proficient at self-injection. B. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns. C. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates. D. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.

B

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the clients diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

B

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the clients pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

B

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. After you wash the surgical site, shave that area with your own razor. b. Be sure to wash the area where you will have surgery very thoroughly. c. Use a washcloth to wash the surgical site; do not take a full shower or bath. d. Wash the surgical site first, then shampoo and wash the rest of your body.

B

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. All preoperative clients get this medication. b. It helps prevent ulcers from the stress of the surgery. c. Since you dont have ulcers, I will have to ask. d. The physician prescribed this medication for you.

B

A nurse manager is mentoring a novice nurse manager in determining staffing needs. The mentor explains, "We must determine the acuity level of the patient by: a. assessing patient satisfaction with nursing care." b. quantifying the amount and intensity of care required." c. examining the skill mix and educational preparation of the staff." d. determining the number of hospital days required by the patients."

B

A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies and no significant health history. Which action should the nurse include in this clients plan of care? a. Initiate Airborne Precautions. b. Offer fluids every hour or two. c. Place an indwelling urinary catheter. d. Palpate the clients thyroid gland.

B

A nurse plans care knowing when specific recovery milestones are expected. The nurse is providing care via: a. patient classification systems. b. clinical pathways. c. functional nursing. d. case management.

B

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. b. Notify the provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation.

B

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, My cousin has depression and is taking this drug. Do you think Im depressed? How should the nurse respond? A. Many people with long-term diabetes become depressed after a while. B. Its for peripheral neuropathy. Do you have burning pain in your feet or hands? C. This antidepressant also has anti-inflammatory properties for diabetic pain. D. No. Many medications can be used for several different disorders.

B

A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? a. Blood urea nitrogen: 12 mg/dL b. Creatinine: 3.2 mg/dL c. Hemoglobin: 8.2 mg/dL d. White blood cell count: 12,000/mm3

B

A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this clients teaching to prevent bloodborne infections? a. Wash your hands after completing each test. b. Do not share your monitoring equipment. c. Blot excess blood from the strip with a cotton ball. d. Use gloves when monitoring your blood glucose.

B

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this clients teaching? A. When ill, avoid eating or drinking to reduce vomiting and diarrhea. B. Monitor your blood glucose levels at least every 4 hours while sick. C. If vomiting, do not use insulin or take your oral antidiabetic agent. D. Try to continue your prescribed exercise regimen even if you are sick.

B

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this clients teaching? A. Change positions slowly when you get out of bed. B. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). C. If you miss a dose of this drug, you can double the next dose. D. Discontinue the medication if you develop a urinary infection.

B

A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this clients teaching to decrease injury?a. Drink at least 2 liters of fluids each day. b. Walk around the neighborhood for daily exercise. c. Bathe your perineal area twice a day. d. You should check your blood glucose before meals.

B

A nursing unit is comparing team nursing to the partnership model and finds that: a. with the partnership model, an RN does not have to be part of the mix. b. leadership abilities of the RN is a major determinant of effectiveness of care for both models. c. the RN teaches the LPN/LVN or unlicensed assistive personnel (UAP) how to apply the nursing process in team nursing. d. with team nursing the RN cares for the patient while the team members work with the family or significant others.

B

A patient has decided to stop hemodialysis because his renal failure progresses and he wishes to spend more time with family. Palliative care will continue, and the approach will be discussed with the patient and family as needed and at change of shift. The care delivery model in this situation is termed: a. partnership. b. patient-centered. c. case management. d. total patient care.

B

A patient is admitted for a hysterectomy, and the RN develops and implements the plan of care but also delegates to the LPN/LVN the responsibility of administering oral medications. While off duty, this RN receives a call requesting a change in the plan of care because the patient has developed deep vein thrombosis. The nurse who originally planned the care is practicing which type of nursing care delivery? a. Modular b. Primary c. Team d. Functional

B

A patient is admitted with coronary artery disease and is scheduled for coronary artery bypass grafting (CABG). According to the clinical pathway the patient should be extubated and discharged from critical care the day after surgery. During surgery the patient's oxygen saturation decreased drastically as a result of chronic tobacco abuse. Subsequently, the patient remained on the ventilator an additional 2 days postoperatively. According to the clinical practice guideline for CABG, this situation represents a: a. patient outcome. b. variance. c. goal. d. standard.

B

A patient is admitted with pneumonia. The case manager refers to a plan of care that specifically identifies dates when supplemental oxygen should be discontinued, positive-pressure ventilation with bronchodilators should be changed to self-administered inhalers, and antibiotics should be changed from intravenous to oral treatment, on the basis of assessment findings. This plan of care is referred to as a: a. patient classification system. b. clinical pathway. c. patient-centered plan of care. d. diagnosis-related group (DRG).

B

A patient must be treated immediately for acute organ transplant rejection. The nurse anticipates that muromonab-CD3 (Orthoclone OKT3) will be ordered. What is the priority assessment before beginning drug therapy with muromonab-CD3? a. Serum potassium level b. Fluid volume status c. Electrocardiogram d. Blood glucose level

B

A patient who has undergone a lung transplant has contracted cytomegalovirus (CMV) retinitis. The nurse expects which drug to be ordered for this patient? a. Acyclovir (Zovirax) b. Ganciclovir (Cytovene) c. Ribavirin (Virazole) d. Amantadine (Symmetrel)

B

A patient will be having oral surgery and has received an antibiotic to take for 1 week before the surgery. The nurse knows that this is an example of which type of therapy? a. Empiric b. Prophylactic c. Definitive d. Resistance

B

A patient with multiple sclerosis will be starting therapy with an immunosuppressant drug. The nurse expects that which drug will be used? a. Azathioprine (Imuran) b. Glatiramer acetate (Copaxone) c. Daclizumab (Zenapax) d. Sirolimus (Rapamune)

B

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

B

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

B

A task force is considering factors that contribute to high-quality safe staffing. Which statement reflects an understanding of the American Nurses Association's (ANA) recommendations? a. Because patient needs remain constant on a daily shift, staffing needs at the beginning of the shift should be sufficient to provide safe, high-quality care. b. Staffing should allow time for the RN to apply the nursing process so decisions result in high-quality, safe patient outcomes. c. Patient acuity levels affect staffing by increasing the need for unlicensed personnel to provide routine basic care rather than increasing RNs in staff mix. d. RN staffing is not cost-effective; thus is it important for staffing models to limit the number of RNs assigned per shift.

B

After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? A. I need to have an annual appointment even if my glucose levels are in good control. B. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick. C. I can still develop complications even though I do not have to take insulin at this time. D. If I have surgery or get very ill, I may have to receive insulin injections for a short time.

B

An appropriate intervention for a patient with neutropenia would be to a. serve only packaged food items. b. cook food items immediately after thawing. c. not serve any fresh fruits or vegetables. d. serve soy-based milk rather than cow's milk.

B

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

B

Category 2 CD4 T-Lymphocyte values are defined as a. less than 200 cells/µL. b. more than 200 cells/µL. c. 200 to 499 cells/µL. d. 800 to 1000 cells/µL.

B

Factors associated with the development of cancer include a. processed foods. b. radiation exposure. c. food-borne disease. d. diabetes mellitus.

B

For patients with cancer, a good source of dietary protein could be a. scrambled eggs. b. applesauce. c. orange sherbet. d. green grapes.

B

Patients who receive chemotherapeutic drugs often develop a. tremors. b. anemia. c. hypertension. d. abnormal heart rhythms.

B

Which nursing diagnosis is appropriate for a patient who has started aminoglycoside therapy? a. Constipation b. Risk for injury (renal damage) c. Disturbed body image related to gynecomastia d. Imbalanced nutrition, less than body requirements, related to nausea

B

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

C

A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients call light, the client presents an appearance as shown below: What action by the nurse takes priority? a. Administer epinephrine 1:1000, 0.3 mg IV push immediately. b. Apply oxygen by facemask at 100% and a pulse oximeter. c. Ensure a patent airway while calling the Rapid Response Team. d. Reassure the client that these manifestations will go away.

C

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

C

A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.

C

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

C

A fundamental effect of HIV infection is a. nausea. b. vomiting. c. major weight loss. d. cirrhosis.

C

A hospital is concerned with nurse retention and realizes that job satisfaction is a major influence. To enhance employee satisfaction related to staffing, the management team: a. negotiates for additional agency nurses. b. hires more part-time employees. c. includes participatory management into staffing decisions. d. uses "float" nurses to cover vacancies.

C

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? A. Document the finding in the clients chart. B. Assess tactile sensation in the clients hands. C. Examine the clients feet for signs of injury. D. Notify the health care provider.

C

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? A. Serum potassium level has increased. B. Blood osmolarity has decreased. C. Glasgow Coma Scale score is unchanged. D. Urine remains negative for ketone bodies.

C

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? A. Encourage the client to use an incentive spirometer. B. Increase the clients intravenous fluid flow rate. C. Consult the provider to test for ketoacidosis. D. Perform meticulous pulmonary hygiene care.

C

A nurse cares for a client who is prescribed a serum catecholamine test. Which action should the nurse take when obtaining the sample?a. Discard the first sample and then begin the collection. b. Draw the blood sample after the client eats breakfast. c. Place the sample on ice and send to the laboratory immediately. d. Add preservatives before sending the sample to the laboratory.

C

A nurse cares for a client with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance should the nurse assess? a. Potassium b. Sodium c. Calcium d. Magnesium

C

A nurse evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value should the nurse assess first? a. Posterior pituitary hormones b. Adrenal medulla hormones c. Anterior pituitary hormones d. Parathyroid hormone

C

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

C

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

C

A patient has a urinary tract infection. The nurse knows that which class of drugs is especially useful for such infections? a. Macrolides b. Carbapenems c. Sulfonamides d. Tetracyclines

C

A patient is receiving cidofovir (Vistide) as part of treatment for a viral infection, and the nurse is preparing to administer probenecid, which is also ordered. Which is the rationale for administering probenecid along with the cidofovir treatment? a. Probenecid has a synergistic effect when given with cidofovir, thus making the antiviral medication more effective. b. The probenecid also prevents replication of the virus. c. Concurrent drug therapy with probenecid reduces the nephrotoxicity of the cidofovir. d. The probenecid reduces the adverse gastrointestinal effects of the cidofovir.

C

A patient is receiving his third intravenous dose of a penicillin drug. He calls the nurse to report that he is feeling "anxious" and is having trouble breathing. What will the nurse do first? a. Notify the prescriber. b. Take the patient's vital signs. c. Stop the antibiotic infusion. d. Check for allergies.

C

A patient who has been hospitalized for 2 weeks has developed a pressure ulcer that contains multidrug-resistant Staphylococcus aureus (MRSA). Which drug would the nurse expect to be chosen for therapy? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Vancomycin (Vancocin) d. Tobramycin (Nebcin)

C

A patient who is diagnosed with shingles is taking topical acyclovir, and the nurse is providing instructions about adverse effects. The nurse will discuss which adverse effects of topical acyclovir therapy? a. Insomnia and nervousness b. Temporary swelling and rash c. Burning when applied d. This medication has no adverse effects.

C

A patient with a long-term intravenous catheter is going home. The nurse knows that if he is allergic to seafood, which antiseptic agent is contraindicated? a. Chlorhexidine gluconate (Hibiclens) b. Hydrogen peroxide c. Povidone-iodine (Betadine) d. Isopropyl alcohol

C

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

C

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drains safety pin to the sheets d. Using sterile technique to empty the drain

C

A young adult calls the clinic to ask for a prescription for "that new flu drug." He says he has had the flu for almost 4 days and just heard about a drug that can reduce the symptoms. What is the nurse's best response to his request? a. "Now that you've had the flu, you will need a booster vaccination, not the antiviral drug." b. "We will need to do a blood test to verify that you actually have the flu." c. "Drug therapy should be started within 2 days of symptom onset, not 4 days." d. "We'll get you a prescription. As long as you start treatment within the next 24 hours, the drug should be effective."

C

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? A. I should increase my intake of vegetables with higher amounts of dietary fiber. B. My intake of saturated fats should be no more than 10% of my total calorie intake. C. I should decrease my intake of protein and eliminate carbohydrates from my diet. D. My intake of water is not restricted by my treatment plan or medication regimen.

C

Customer satisfaction is primarily based on: a. access to modern, up-to-date facilities. b. availability of an extensive menu selection. c. personal interactions with employees. d. having to undergo fewer invasive procedures.

C

Guidelines for counseling a person with HIV infection include a. recommending intake of specific combinations of food. b. expecting significant changes in lifestyle behaviors. c. promoting optimal nutrition while making the fewest food changes. d. acting as a catalyst for selecting appropriate lifestyle changes.

C

If salivary secretions are reduced or absent, it may be most helpful to a. serve a clear liquid diet. b. use a tube feeding. c. serve food in semiliquid form. d. serve water with the meal.

C

Mr. T has been undergoing treatment for cancer and has not felt like eating all day and complains of much discomfort and pain. Of the following, which may be an initial intervention to assist in increasing his appetite? a. administering medication to increase appetite as soon as possible b. assessing for weight loss and speaking with the physician regarding tube feeding c. assessing pain and discomfort and providing pain relief measures d. changing the diet plan to all liquids to make it easier to ingest food items

C

Mucositis is an inflammation of the a. stomach mucosa. b. intestinal mucosa. c. oral mucosa. d. pancreas.

C

The capacity of the immune system is compromised by a. increased metabolism of water-soluble vitamins. b. increased metabolism caused by emotional stress. c. severe malnutrition with atrophy of organs and tissues. d. increased hormonal levels associated with stress.

C

The cells responsible for synthesis and secretion of antibodies are the a. immunoglobulins. b. T cells. c. cells. d. lymphocytes.

C

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken d. Obtain a new pair of sterile gloves for the surgeon to put on.

C

When deciding which staffing option to use on a nursing unit that will open soon, the manager realizes that: a. continuity of care is enhanced and errors are reduced when nurses provide care over longer shifts and consecutive workdays, such as 12-hour shifts on 3 consecutive days per week. b. the use of part-time nurses provides the variability needed to meet diverse patient needs. c. satisfaction of the staff equates to satisfaction of patients. d. nurses provide the same level of care, regardless of the work environment.

C

When reviewing the allergy history of a patient, the nurse notes that the patient is allergic to penicillin. Based on this finding, the nurse would question an order for which class of antibiotics? a. Tetracyclines b. Sulfonamides c. Cephalosporins d. Quinolones

C

.A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? A. Administration of oxygen via face mask B. Intravenous administration of 10% glucose C. Implementation of seizure precautions D. Administration of intravenous insulin

D

.A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? A. Pioglitazone (Actos) B. Glimepiride (Amaryl) C. Glipizide (Glucotrol) D. Metformin (Glucophage)

D

A 79-year-old patient is receiving a quinolone as treatment for a complicated incision infection. The nurse will monitor for which adverse effect that is associated with these drugs? a. Neuralgia b. Double vision c. Hypotension d. Tendonitis and tendon rupture

D

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

D

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

D

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.

D

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the clients chart. d. Ensure the information is relayed to the surgical team.

D

A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem? a. Reduced physical activity related to the diseases effects on the lungs b. Inadequate family coping related to the clients hospitalization c. Inadequate knowledge related to the plasmapheresis process d. Potential for infection related to the site for organism invasion

D

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

D

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

D

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

D

A hospital unit is participating in a bioterrorism drill. A client is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the client? a. Airborne Precautions b. Contact Precautions c. Droplet Precautions d. Standard Precautions

D

A major systemic effect of cancer is a. edema. b. hypoglycemia. c. dehydration. d. negative nitrogen balance.

D

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? A. Apply ice to the site to reduce inflammation. B. Consult the provider for a new administration route. C. Assess the client for other signs of cellulitis. D. Instruct the client to rotate sites for insulin injection.

D

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? A. A 29-year-old Caucasian B. A 32-year-old African- American C. A 44-year-old Asian D. A 48-year-old American Indian

D

A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond? A. Drinking any wine or alcohol will increase your insulin requirements. B. Because of poor kidney function, people with diabetes should avoid alcohol. C. You should not drink alcohol because it will make you hungry and overeat. D. One glass of wine is okay with a meal and is counted as two fat exchanges.

D

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure you keep all your postoperative appointments. b. Call your surgeon if you have any questions at home. c. Eat a diet high in protein, iron, zinc, and vitamin C. d. Wash your hands before touching the drain or dressing.

D

A nurse makes patient care assignments as follows: RN1 has rooms 200-210; RN2 has rooms 211-221; RN3 has rooms 222-232. The two unlicensed assistive personnel have half the rooms, with one assigned to 200-215 and the second to 216-232. The care delivery model used in this situation is: a. team. b. primary. c. partnership. d. modular.

D

A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment? a. Stand in front of the client instead of behind the client. b. Ask the client to swallow after palpating the thyroid. c. Palpate the right lobe with the nurses left hand. d. Place the client in a sitting position with the chin tucked down.

D

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria? A. Serum sodium: 163 mEq/L B. Serum creatinine: 1.6 mg/dL C. Presence of urine ketone bodies D. Serum osmolarity: 375 mOsm/kg

D

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? A. Serum chloride level of 98 mmol/L B. Serum calcium level of 8.8 mg/dL C. Serum sodium level of 132 mmol/L D. Serum potassium level of 2.5 mmol/L

D

A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this clients discharge education? A. Test your urine daily for ketones. B. Use only buffered insulin in your pump. C. Store the insulin in the freezer until you need it. D. Change the needle every 3 days.

D

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this clients teaching to prevent injury? A. Examine your feet using a mirror every day. B. Rotate your insulin injection sites every week. C. Check your blood glucose level before each meal. D. Use a bath thermometer to test the water temperature.

D

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this clients teaching to decrease the clients insulin needs? A. Limit your fluid intake to 2 liters a day. B. Animal organ meat is high in insulin. C. Limit your carbohydrate intake to 80 grams a day. D. Walk at a moderate pace for 1 mile daily.

D

A patient has an order for cyclosporine (Sandimmune). The nurse finds that cyclosporine-modified (Neoral) is available in the automated medication cabinet. Which action by the nurse is correct? a. Hold the dose until the prescriber makes rounds. b. Give the cyclosporine-modified drug. c. Double-check the order, and then give the cyclosporine-modified drug. d. Notify the pharmacy to obtain the Sandimmune form of the drug.

D

A patient has been diagnosed with carbapenemase-resistant Enterobacteriaceae (CRE). The nurse expects to see orders for which drug? a. Dapsone (Cubicin), a miscellaneous antibiotic b. Ciprofloxacin (Cipro), a quinolone c. Linezolid (Zyvox), an oxazolidinone d. Colistimethate sodium (Coly-Mycin), a polypeptide antibiotic

D

A patient is admitted with a fever of 102.8° F (39.3° C), origin unknown. Assessment reveals cloudy, foul-smelling urine that is dark amber in color. Orders have just been written to obtain stat urine and blood cultures and to administer an antibiotic intravenously. The nurse will complete these orders in which sequence? a. Blood culture, antibiotic dose, urine culture b. Urine culture, antibiotic dose, blood culture c. Antibiotic dose, blood and urine cultures d. Blood and urine cultures, antibiotic dose

D

A patient is taking a combination of antiviral drugs as treatment for early stages of a viral infection. While discussing the drug therapy, the patient asks the nurse if the drugs will kill the virus. When answering, the nurse keeps in mind which fact about antiviral drugs? a. They are given for palliative reasons only. b. They will be effective as long as the patient is not exposed to the virus again. c. They can be given in large enough doses to eradicate the virus without harming the body's healthy cells. d. They may also kill healthy cells while killing viruses.

D

A patient who is HIV- positive has been receiving medication therapy that includes zidovudine (Retrovir). However, the prescriber has decided to stop the zidovudine because of its dose-limiting adverse effect. Which of these conditions is the dose-limiting adverse effect of zidovudine therapy? a. Retinitis b. Renal toxicity c. Hepatotoxicity d. Bone marrow suppression

D

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

D

Accrediting agencies such as The Joint Commission address staffing by: a. imposing maximum staffing levels. b. requiring a specific staff mix. c. stipulating nurse-patient ratios. d. looking for evidence that patients receive satisfactory care.

D

After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? A. I have so many complications; exercising is not recommended. B. I will exercise more frequently because I have so many complications. C. I used to run for exercise; I will start training for a marathon. D. I should look into swimming or water aerobics to get my exercise.

D

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? A. Ill take this medicine during each of my meals. B. I must take this medicine in the morning when I wake. C. I will take this medicine before I go to bed. D. I will take this medicine immediately before I eat.

D

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. At my age, I should continue seeing the ophthalmologist as I usually do. b. I will see the eye doctor when I have a vision problem and yearly after age 40 c. My vision will change quickly. I should see the ophthalmologist twice a year. d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

D

An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

D

An infant has been hospitalized with a severe lung infection caused by the respiratory syncytial virus (RSV) and will be receiving medication via the inhalation route. The nurse expects which drug to be used? a. Acyclovir (Zovirax) b. Ganciclovir (Cytovene) c. Amantadine (Symmetrel) d. Ribavirin (Virazole)

D

An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids d. Treat the client as if he or she has tuberculosis (TB).

D

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best? a. Everyone comes out of surgery differently. b. Lets just give her some more time, okay? c. She may have had a stroke during surgery. d. Sometimes older people take longer to wake up.

D

An orthopedic unit is considering different types of care delivery models and staff have an opportunity to ask questions about how the models differ. The nurse manager provides an overview and uses the above visual to demonstrate which model of care delivery? a. Team b. Partnership c. Primary d. Functional

D

Cyclosporine is prescribed for a patient who had an organ transplant. The nurse will monitor the patient for which common adverse effect? a. Nausea and vomiting b. Fever and tremors c. Agitation d. Hypertension

D

During drug therapy with a tetracycline antibiotic, a patient complains of some nausea and decreased appetite. Which statement is the nurse's best advice to the patient? a. "Take it with cheese and crackers or yogurt." b. "Take each dose with a glass of milk." c. "Take an antacid with each dose as needed." d. "Drink a full glass of water with each dose."

D