Physiological adaptation practice exam

A nurse is caring for a client who is pregnant. next gen

limit carbs, non stress test, and anticipate metformin.

A nurse is caring for an infant in the emergency department. next gen

measure head circumference, asses pupil reaction, and palpate fontanel

A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching?

"Avoid eating tree nuts, such as almonds."

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?

"Bring your baby in to the clinic today."

A nurse in the labor and delivery unit is caring for a client who is pregnant. next gen

gestational age, vaginal exam, uterine contractions, and birthing parents pain.

A nurse in the emergency department is caring for client who is experiencing chest pain. next gen

give oxygen and aspirin, most likely having an MI, monitor EKG and vitals.

A nurse is caring for an 18-month-old toddler in the emergency department. next gen

high dose IVIG, and aspirin

A nurse is caring for an adolescent who presents to the emergency department. (next gen)

improved- respiratory, o2 sat, oral intake, hr, and blood pressure.

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

increased HR, BP, RR,

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (

jawthrust, assess vent, IV access, GSC, and remove clothing

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

"These tests help determine the degree of damage to the heart tissues."

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

"I will apply heat."

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

"It is caused by the lack of production of aldosterone by the adrenal gland."

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

"We will give our child pancreatic enzymes with snacks and meals."

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?

1370

A nurse is reviewing the transfer report on a client. next gen.

70 year old male with abdominal pain, upper abdomen distention with decreased bowel sounds, orange brown nausea, last bowel movement was 7 days ago

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?

Administer antibiotic therapy.

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome?

Alopecia, moon face, purple striations, and buffalo hump

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Check the catheter tubing for kinks or twisting.

A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?

Crushed ice

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Decreased level of consciousness

A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care.

Elevated the head of bed and encourage a low sodium diet. The client could have heart failure. Monitor blood pressure and urine

A nurse is caring for a client in the emergency department (ED). next gen

Encephalopathy as evidence by ammonia

A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

Establish a reward system for positive behavior.

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Heart rate

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

Nausea and vomiting

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Pacemaker spikes before each QRS complex

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Prevent aspiration.

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

Recombinant

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?

Serum creatinine

A nurse in the emergency department is caring for a 60-year-old client

Should check stool sample and request for a PPI, at risk of peptic ulcer disease. monitor orthostatic blood pressure and hemoglobin and hematocrit

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

Stop the infusion of blood.

A nurse in the emergency department is caring for a client who has an elevated temperature and reports fatigue and muscle aches. (next gen)

Supplemental oxygen, obtain a chest xray, and request an rx for dexamethasone

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Talk with the client during wound care.

A nurse is caring for a 7-year-old child. next gen

Temperature is consistent with leukemia and sickle cell anemia. Bruising is consistent with leukemia and hemophilia. Bleeding is consistent with leukemia and hemophilia WBC count is consistent with leukemia and sickle cell anemia. Pain is consistent with leukemia, sickle cell anemia, and hemophilia.

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

To prevent fluid from accumulating in the wound

A nurse is caring for a client who is at 32 weeks of gestation.

UA is nonessential, mg sulfate and bp q15 are anticipated, supine is contraindicated.

A nurse s caring for a client. painful sores on the perineum

acyclovir as evidence by perineal lesions.

A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.

box on the far right

A nurse is caring for a 5-year-old child in the acute care setting. (next gen)

child uncooperative, reports chest pain as 4, nasal flaring, bilateral wheezing are correct

A nurse is caring for a newborn who is 4 hr old. next gen

clavicle fracture, as evident by moro reflex

A nurse is caring for a client who has cancer and is undergoing chemotherapy. next gen

oral health and bleeding episodes

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

A nurse is caring for a client who has a new diagnosis of lung cancer. (next gen)

place the client is a private room and rinse the mouth are anticipated, indwelling catheter and rectal temps are contraindicated, and droplet precautions are non essential.

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)

protein, phosphorus, and sodium

A nurse is caring for a 4-year-old child who has an atrial septal defect (ASD).

temperature, right groin pressure dressing, right leg is warm, pedal and popliteal pulses are strong, apical HR is regular

A nurse is caring for a client who has a pneumothorax. next gen

thoracentesis is contraindicated, abgs, chest tube, IV access are anticipated, the CT and PFT are non-essential.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

turn the head to the side