Concepts-Exam 1

The nurse is caring for a patient who is 5'6" tall and weighs 186 lb. The nurse has discussed reasonable weight loss goals and a low-calorie diet with the patient. Which statement made by the patient indicates a need for further teaching? A. "I will limit intake to 500 calories a day." B. "I will try to eat very slowly during mealtimes." C. "I'll try to pick foods from all of the basic food groups." D. "It's important for me to begin a regular exercise program."

A. "I will limit intake to 500 calories a day."

The nurse instructs an obese 22-yr-old man with a sedentary job about the health benefits of an exercise program. The nurse evaluates that teaching is effective when the patient makes which statement? A. "The goal is to walk at least 10,000 steps every day of the week." B. "Weekend aerobics for 2 hours is better than exercising every day." C. "Aerobic exercise will increase my appetite and result in weight gain." D. "Exercise causes weight loss by decreasing my resting metabolic rate."

A. "The goal is to walk at least 10,000 steps every day of the week."

The stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply.)? A. Administer bolus or continuous feedings. B. Evaluate the nutritional status of the patient. C. Administer medications through the gastrostomy tube. D. Monitor for complications related to the tube and enteral feeding. E. Teach the caregiver about feeding via the gastrostomy tube at home.

A. Administer bolus or continuous feedings. C. Administer medications through the gastrostomy tube.

A young male patient is seeking treatment for recurrence of genital tingling, burning, and itching. The nurse will expect a prescription for which class of medications? A. Antiviral B. Antibiotics C. Vaccination D. Contraceptives

A. Antiviral

A community health nurse is conducting an initial assessment of a new patient. Which assessments should the nurse include when screening the patient for metabolic syndrome (select all that apply.)? A. Blood pressure B. Resting heart rate C. Physical endurance D. Waist circumference E. Fasting blood glucose

A. Blood pressure D. Waist circumference E. Fasting blood glucose

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.) A. Body mass index (BMI) of 17 B. waist-to-hip ratio of 1.0 C. Weight loss of 6% since last month's visit D. Prealbumin level of 16mg/dL E Hematocrit level of 50% F. hemoglobin level of 8.2g/dL

A. Body mass index (BMI) of 17 C. Weight loss of ^% since last month's visit F. hemoglobin level of 8.2g/dL

Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? A. Engagement B. Extension C. Internal rotation D. External rotation

A. Engagement

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A. A Caucasian female who is 39 weeks gestation. B. An African-American female who is breastfeeding C. An Asian female diagnosed with hypoglycemia. D. A Hispanic female who has a BMI of 24.1.

An African-American female who is breastfeeding

Which maternal factor may inhibit fetal descent? A. Decreased peristalsis B. A full bladder C. Reduction in internal uterine size D. Rupture of membranes

B. A full bladder

A 52-yr-old man with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective? A. Negative bacterial culture B. Absence of genital lesions C. Reduction of genital warts D. No drainage from chancre sore

B. Absence of genital lesions

The patient is being treated for a recurrent episode of Chlamydia. What should the nurse include in patient teaching? A. If you are treated, your sexual partner will not need to be treated. B. Abstain from sexual intercourse for 7 days after finishing the treatment. C. You will probably get gonorrhea if you have another recurrence of Chlamydia. D. Because you have been treated before, you do not need to take a full course of medication this time.

B. Abstain from sexual intercourse for 7 days after finishing the treatment.

The nurse is caring for a patient after bariatric surgery. What should be included in the plan of care (select all that apply.)? A. Teach the patient to increase carbohydrate intake. B. Assess for incisional pain versus anastomosis leak. C. Maintain elevation of the head of bed at 35-45 degrees. D. Monitor for vomiting that is a common complication. E. Instruct the patient to consume liquids frequently during meals. F. Assist with early independent ambulation during hospitalization.

B. Assess for incisional pain versus anastomosis leak. C. Maintain elevation of the head of bed at 35-45 degrees. D. Monitor for vomiting that is a common complication. F. Assist with early independent ambulation during hospitalization.

A patient is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient? A. Muscle weakness B. Cardiac dysrhythmias C. Increased urine output D. Anemia and leukopenia

B. Cardiac dysrhythmias

A woman just gave birth to her sixth child. She states to the nurse, "I just can't have another baby, but I don't want surgery to prevent it either. What can I do?" What contraceptive method can the nurse suggest to the woman as being the most effective? A. Cervical cap B. Copper IUD C. Condoms D. Diaphragm

B. Copper IUD

A woman is expecting her first baby in 7 months. During the nurse's assessment Anna continues to ask questions about changes in her body. The nurse can recommend which type of class to assist the woman with her questions? A. Preconception class B. Early pregnancy class C. Childbirth preparation class D. Parenting class

B. Early pregnancy class

The nurse is monitoring the fetal heart rate periodically with Doppler auscultation. At the end of a contraction, the fetal heart rate is 100 and gradually increases to 140 within 30 seconds. The nurse would need to assess the rate further, because this is an indication of A. low variability. B. late deceleration. C. early deceleration. D. variable deceleration.

B. late deceleration.

Thirty minutes after delivery, the nurse can expect to palpate the fundus A. at the umbilicus. B. midway between the symphysis pubis and umbilicus. C. at the symphysis pubis. D. above the umbilicus.

B. midway between the symphysis pubis and umbilicus.

A woman is concerned that she has developed numerous nosebleeds during this pregnancy. She feels this is a sign of leukemia and wants to be screened. The nurse's response to the woman should be based on the fact that A. leukemia is a major concern during pregnancy. B. nosebleeds are a common occurrence during pregnancy. C. nosebleeds are rare in pregnancy; therefore further assessment is necessary. D. platelet count decreases significantly during pregnancy.

B. nosebleeds are a common occurrence during pregnancy.

A 19-yr-old man comes to the outpatient clinic for treatment of uncomplicated gonorrhea. Which patient statement requires immediate clarification by the nurse? A. "I should avoid alcohol intake for at least 2 weeks" B. "I will have me sexual partner come in for treatment" C. "After I start the antibiotic, it is safe to have sex again" D. "After the treatment, I do not need to return to the clinic for retesting"

C. "After I start the antibiotic, it is safe to have sex again"

In working with teenagers, what should the nurse include when teaching about prevention of STIs? A. Spermicidal jellies reduce the risk of getting STIs. B. STIs are easily cured so prevention is not important. C. Abstinence and then condoms are the best prevention. D. Douches for women and cleaning the penis will prevent STIs.

C. Abstinence and then condoms are the best prevention.

The nurse recognizes that the majority of patients' caloric needs should come from which source? A. Fats B. Proteins C. Polysaccharides D. Monosaccharides

C. Polysaccharides

The nurse is providing care for a patient who is a strict vegetarian. Which dietary choices would the nurse recommend to prevent iron deficiency? A. Brown rice and kidney beans B. Cauliflower and egg substitutes C. Soybeans and hot breakfast cereal D. Whole-grain bread and citrus fruits

C. Soybeans and hot breakfast cereal

In developing an effective weight reduction plan for an overweight patient who expresses willingness to try to lose weight, which factor should the nurse assess first? A. The length of time the patient has been obese B. The patient's current level of physical activity C. The patient's social, emotional, and behavioral influences on obesity D. Anthropometric measurements, such as body mass index and skinfold thickness

C. The patient's social, emotional, and behavioral influences on obesity

The physician noted that the woman was 7 cm dilated and 100% effaced. The nurse is aware that the woman is in which phase of labor? A. Latent B. Active C. Transition D. Second

C. Transition

During prenatal teaching it is important for the nurse to inform the patient about danger signs in pregnancy. Which sign need to be reported immediately to the health care provider? A. Clear mucous vaginal discharge B. Frequent urination C. Vaginal bleeding D. Backache that occurs after standing for a long period

C. Vaginal bleeding

The history and physical of a 29-yr-old female patient are indicative of human papillomavirus (HPV) infection. What treatment option should be discussed with the patient? A. Gardasil B. Antibiotic treatment C. Wart removal options D. Treatment with antiviral drugs

C. Wart removal options

To initiate the milk ejection reflex, the mother should A. wear a firm-fitting bra. B. drink plenty of fluids. C. place the infant to the breast. D. apply cool packs to her breasts.

C. place the infant to the breast.

A woman is seeing the nurse practitioner for her yearly Pap smear. She tells the nurse that she has heard of a nonsurgical sterilization method and that she is interested in more information. The nurse's teaching should be based on the knowledge that A. there is no such procedure available at this time. B. the procedure can be performed in the physician's office, but it is not permanent and will need to be repeated every 5 years. C. the procedure will permanently block the fallopian tubes, but another method of birth control must be used until a hysterosalpingogram proves blockage. D. the procedure has a low success rate and should be used only in women who cannot tolerate other methods of birth control.

C. the procedure will permanently block the fallopian tubes, but another method of birth control must be used until a hysterosalpingogram proves blockage.

While summarizing teaching regarding genital herpes, which patient statement indicates a need for further instruction? A. "No cure is available for my genital herpes" B. " I will utilize my medication when I begin to have symptoms" C. Genital herpes may be caused by herpes simplex virus type 1 to 2" D. "I am not able to infect a sexual partner unless I have active lesions"

D. "I am not able to infect a sexual partner unless I have active lesions"

While summarizing teaching regarding genital herpes, which patient statement indicates a need for further instruction? A. "No cure is available for my genital herpes." B. "I will utilize my medication when I begin to have symptoms." C. "Genital herpes may be caused by herpes simplex virus type 1 or 2" D. "I am not able to infect a sexual partner unless I have active lesions."

D. "I am not able to infect a sexual partner unless I have active lesions."

At the first visit to the clinic, the female patient with a BMI of 29 kg/m2 tells the nurse that she does not want to become obese. Which question used for assessing weight issues would be most effective? A. "What factors contributed to your current body weight?" B. "How is your overall health affected by your body weight?" C. "What is your history of gaining weight and losing weight?" D. "In what ways are you interested in managing your weight differently?"

D. "In what ways are you interested in managing your weight differently?"

Which patient has the morbidity risk? A. Male 6 ft, 1 in. tall; BMI 29 kg/m2 B. Female 5 ft, 6 in. tall; weight 150 lb C. Male with waist circumference 46 in D. Female 5 ft, 10 in. tall; obesity class III

D. Female 5 ft, 10 in. tall; obesity class III

In the immediate postoperative period a nurse cares for a severely obese 72-yr-old man who had surgery for repair of a lower leg fracture. Which assessment is mostimportant? A. Cardiac rhythm B. Surgical dressing C. Postoperative pain D. Oxygen saturation

D. Oxygen saturation

A nurse is supervising a student nurse who is assessing an infant's rooting reflex. Which action by the student warrants further instruction by the nurse? A. Tells parents this reflex will disappear within 4 months B. Strokes face from side of mouth to cheek C. Notes normal findings when infant turns head toward touch D. Performs assessment on infant while sleeping

D. Performs assessment on infant while sleeping

A patient received a small-bore nasogastric (NG) tube after a laryngectomy. Which action has the highest priority before initiating enteral feedings? A. Testing aspirated fluid pH B. Auscultating while instilling air C. Elevating head of bed to 40 degrees D. Verifying NG tube placement on x-ray

D. Verifying NG tube placement on x-ray

The nurse is caring for a 25-year-old woman who is requesting information to lose weight. What information will the nurse include in a weight-loss plan? A. Weigh yourself at the same time every morning and evening. B. Stick to a 600- to 800-calorie diet for the most rapid weight loss. C. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. D. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

The nurse obtains a history from a 34-yr-old woman diagnosed with a chlamydial infection. Which patient statement indicates additional teaching is required? A. This infection can be cured by taking antibiotics." B. "It is important to use condoms for all sexual activity." C. "I will avoid sexual contact for 1 week after taking the antibiotics." D. My sexual partner does not have symptoms and will not need treatment."

My sexual partner does not have symptoms and will not need treatment."

The nurse is caring for a 50-year-old man who has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that is high in: A. Iron B. Protein C. Calories D. Carbohydrate

Protein

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? A. Vitamin B12 B. Vitamin C C. Vitamin D D. Omega-3 fatty acids

Vitamin B12

A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest promoting relief? a. "eat dry crackers before you get out of bed." b. "increase your fat intake before bedtime" c. "drink high-carbohydrate fluid with meals." d. "eat two small meals a day and a snack at noon."

a. "eat dry crackers before you get out of bed."

The embryonic period is critical because external and internal structures in the fetus are forming. All teratogens should be avoided from a. 4 to 8 weeks b. 8 to 12 weeks c. 16 to 20 weeks d. 12 to 16 weeks

a. 4 to 8 weeks

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? a. First b. Second c. Prodromal d. Transitional

a. First

Health risks associated with obesity include (select all that apply) a. colorectal cancer. b. rheumatoid arthritis. c. polycystic ovary syndrome. d. nonalcoholic steatohepatitis. e. systemic lupus erythematosus.

a. colorectal cancer. c. polycystic ovary syndrome. d. nonalcoholic steatohepatitis.

While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 100/70 mm Hg, pulse is 72 beats per minutes, and respirations are 16 beats per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? a. Recording these expected findings b. Obtaining an order for an oxytocic medication c. Asking the client when she last changed her perineal pad d. Notifying the primary healthcare provider that the client may be hemorrhaging

c. Asking the client when she last changed her perineal pad

What is the best way for the nurse to promote and support the maternal-infant bonding process? A. Help the mother identify her positive feelings toward the newborn. B. Encourage the mother to provide all newborn care. C. Assist the family with rooming-in. D. Return the newborn to the nursery during sleep periods.

C. Assist the family with rooming-in.

Appropriate approaches used by the long-term care nurse to provide education for a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply.) A. Schedule a visit by another resident who is diabetic B. Demonstrate food choices using food photographs C. Avoid discussion of the patient's favorite foods D. Remind the patient that a lot of damage has already occurred E. encourage the patient's family to participate in teaching sessions F. Ask the patient about past experiences with lifestyle changes

-Schedule a visit by another resident who is diabetic -Demonstrate food choices using food photographs -Encourage the patient's family to participate in teaching sessions -Ask the patient about past experiences with lifestyle changes

A patient is being admitted with anorexia nervosa. Which clinical manifestations should the nurse anticipate? A. Sensitivity to heat, fatigue, and polycythemia B. Hair loss; dry, yellowish skin; and constipation C. Tented skin turgor, hyperactive reflexes, and diarrhea D. Dysmenorrhea, hypoactive bowel sounds, and hunger

B. Hair loss; dry, yellowish skin; and constipation

The nurse has just started a new shift and is reviewing the chart for her assigned patient. The patient is 6 cm dilated, 100% effaced, -3 station with intact membranes. Ten minutes later, the patient informs the nurse that her membranes have just ruptured. The nurse notices variable decelerations on the monitor. The nurse's next action should be to A. perform a vaginal exam. B. increase the intravenous fluids and start oxygen. C. notify the nurse-midwife. D. nothing, this is normal immediately after membranes rupture.

A. perform a vaginal exam.

The nurse cares for a 34-yr-old woman after bariatric surgery. The nurse determines that discharge teaching related to diet is successful if the patient makes which statement? A. "A high-protein diet that is low in carbohydrates and fat will prevent diarrhea." B. "Food should be high in fiber to prevent constipation from the pain medication." C. "Three meals a day with no snacks between meals will provide optimal nutrition." D. "Fluid intake should be at least 2000 mL per day with meals to avoid dehydration."

A. "A high-protein diet that is low in carbohydrates and fat will prevent diarrhea."

A young male patient is seeking treatment for recurrence of genital tingling, burning, and itching. The nurse will expect a prescription for which class of medications? A. Antivirals B. Antibiotics C. Vaccination D. Contraceptives

A. Antivirals

A patient comes to the clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the patient for what characteristic finding of syphilis in the primary clinical stage? A. Chancre B. Alopecia C. Condylomata Alta D. Regional adenopathy

A. Chancre

A patient comes to the clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the patient for what characteristic finding of syphilis in the primary clinical stage? A. Chancre B. Alopecia C. Condylomata lata D. Regional adenopathy

A. Chancre

A woman is expecting her second child. She expressed concern to the nurse about how her 4-year-old will adapt to the new baby. The following are some suggestions the nurse should include in her teaching. (Select all that apply.) A. Come in and listen to the baby's heartbeat. B. Spend more time with grandmother to prepare him for being away from mother during the birth. C. Take a sibling class offered by the hospital. D. Decide which of your toys you would like to give to the new baby.

A. Come in and listen to the baby's heartbeat. B. Spend more time with grandmother to prepare him for being away from mother during the birth. C. Take a sibling class offered by the hospital.

The nurse teaches a 50-yr-old woman who has a body mass index (BMI) of 39 kg/m2 about weight loss. Which dietary change would be most appropriate to recommend? A. Decrease fat intake and control portion size. B. Increase vegetables and decrease fluid intake. C. Increase protein intake and avoid carbohydrates. D. Decrease complex carbohydrates and limit fiber.

A. Decrease fat intake and control portion size.

A nurse is assessing a menopausal female and discussing sexuality. Which statement is accurate regarding physiological effects of menopause on sexual health? A. Decreased lubrication is frequently cited as the cause for sexual problems B. Women who have undergone hysterectomy no longer desire to be sexually active C. Hot flashes are often bothersome and lead to decreased sexual interest D. Women taking hormone replacement therapy may not experience climax during sex

A. Decreased lubrication is frequently cited as the cause for sexual problems

A malnourished patient has been diagnosed with protein deficiency. Which complications should the nurse anticipate (select all that apply.)? A. Edema B. Asthma C. Anemia D. Malabsorption syndrome E. Impaired wound healing F. Gastrointestinal bleeding

A. Edema C. Anemia E. Impaired wound healing

After identifying that a patient has possible nutritional deficits, which action will the nurse perform next? A. Provide supplements between meals. B. Encourage eating meals with others. C. Have family bring in food from home. D. Complete a full nutritional assessment.

D. Complete a full nutritional assessment.

The patient has parenteral nutrition (PN) infusing with amino acids and dextrose. During shift change, the nurse reports the tubing, bag, and dressing were changed 20 hours ago. What care should the incoming nurse plan to deliver (select all that apply.)? A. Giving the patient insulin if needed B. Ensuring that the next bag has been ordered C. Checking amount of solution left in the bag D. Assessing the insertion site and change the tubing E. Verifying the accuracy of the new solution and ingredients

A. Giving the patient insulin if needed B. Ensuring that the next bag has been ordered C. Checking amount of solution left in the bag E. Verifying the accuracy of the new solution and ingredients

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? A. Hypoglycemia B. Hypercalcemia C. Hypobilirubinemia D. Hypoinsulinemia

A. Hypoglycemia

According to the recommendations of the American Academy of Pediatrics (AAP) on infant nutrition A. Infants should be given only human milk for the first 6 months of life. B. Infants fed on formula should be started on solid food sooner than breastfed infants. C. If infants are weaned from breast milk before 12 months, they should receive cow's milk, not formula. D. After 6 months, mothers should shift from breast milk to cow's milk.

A. Infants should be given only human milk for the first 6 months of life.

During a pelvic exam the nurse feels the fetal posterior fontanel toward the woman's left side and anterior. The nurse would report the position as A. LOA. B. ROA. C. LOP. D. ROP.

A. LOA.

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? A. Letting go B. Taking hold C. Taking in

A. Letting go

Rh immune globulin will be ordered postpartum if which situation occurs? A. Mother is Rh negative, baby is Rh positive. B. Mother is Rh negative, baby is Rh negative. C. Mother is Rh positive, baby is Rh positive. D. Mother is Rh positive, baby is Rh negative.

A. Mother is Rh negative, baby is Rh positive.

A 50-yr-old African American woman has a body mass index (BMI) of 35 kg/m2, type 2 diabetes mellitus, hypercholesterolemia, and irritable bowel syndrome (IBS). She is seeking assistance in losing weight because, "I have trouble stopping eating when I should, but I do not want to have bariatric surgery." Which drug therapy should the nurse question if it is prescribed for this patient? A. Orlistat (Xenical) B. Lorcaserin (Belviq) C. Phentermine (Adipex-P) D. Phentermine and topiramate (Qsymia)

A. Orlistat (Xenical)

What should teaching for patients with a sexually transmitted infection (STI) include (select all that apply.)? A. Treatment of sexual partners B. Douching may help to provide relief of itching. C. Importance of retesting after treatment to confirm cure D. Cotton undergarments are preferred over synthetic materials. E. Sexual abstinence is indicated during the communicable phase of the disease. F. Condoms should be used during as well as after treatment during sexual activity.

A. Treatment of sexual partners C. Importance of retesting after treatment to confirm cure D. Cotton undergarments are preferred over synthetic materials. E. Sexual abstinence is indicated during the communicable phase of the disease. F. Condoms should be used during as well as after treatment during sexual activity.

What can be determined only by electronic fetal monitoring? A. Variability B. Tachycardia C. Bradycardia D. Fetal response to contractions

A. Variability

A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called A. acrocyanosis B. erythema neonatorum. C. harlequin color. D. vernix caseosa.

A. acrocyanosis

During her first prenatal visit to the clinic, a woman gives the following obstetric history: a boy born 9 years ago at full term, twin girls born 5 years ago at 36 weeks, a miscarriage at 9 weeks 2 years ago. The nurse correctly records her obstetric history as A. gravida 4, para 2, aborta 1. B. gravida 3, para 3, aborta 1. C. gravida 4, para 3, aborta 1. D. gravida 3, para 2, aborta 1.

A. gravida 4, para 2, aborta 1.

During labor, a woman has been hyperventilating. She begins to complain of tingling in her hands and dizziness. The next action by the nurse should be to A. help the woman slow her breathing and to breathe into a paper bag. B. help the woman onto her side and check her vital signs. C. continue to monitor the woman; this is considered normal. D. assess the need for pain control.

A. help the woman slow her breathing and to breathe into a paper bag.

The procedure in which ova are removed, mixed with sperm, and the fertilized ova are returned to the woman's uterus is called A. in vitro fertilization. B. gamete intrafallopian transfer. C. intracytoplasmic sperm injection. D. therapeutic insemination.

A. in vitro fertilization.

A woman returns to the clinic with her 4-month-old infant for a well-baby visit. She tells the nurse that she cannot afford formula anymore and has started the baby on whole milk. The nurse should assist the woman in finding funding for the formula because unmodified cow's milk A. is not recommended for children under 12 months. B. cannot be sterilized properly. C. may contain bacteria that will cause diarrhea in infants. D. contains higher levels of lactose.

A. is not recommended for children under 12 months.

A semen analysis shows a sperm concentration of 2 million/mL. In explaining this result to a couple, the nurse can base her answer on the knowledge that A. normal sperm concentration is 20 million/mL or greater. B. normal sperm concentration is greater than 1 million/mL. C. there is no "normal" sperm analysis; each is individual. D. the pH of the semen is more important than the sperm concentration.

A. normal sperm concentration is 20 million/mL or greater.

The nurse notes that the hemoglobin level of a woman at 35 weeks of gestation is 11.5 g/dL. The nurse's next action should be to A. note that this is within the normal range for pregnancy. B. note that this is within the normal range for an average adult. C. call the physician; this shows mild anemia. D. recall that the RBC count increases slightly during pregnancy.

A. note that this is within the normal range for pregnancy.

The physician obtains a sample of fetal scalp blood to evaluate the pH. The results of the pH were 7.35. The nurse knows the next action will be A. nothing—this is a normal pH. B. preparing for delivery—the pH shows acidosis. C. preparing for delivery—the pH shows alkalosis. D. repeating the pH in 20 minutes, because it is borderline.

A. nothing—this is a normal pH.

A woman is 2 days postpartum. Her current lab work shows a WBC level of 17,000/mm3. The nurse's next action should be A. nothing—this is in the acceptable range. B. to notify the physician. C. to ask for a retest. D. to force fluids.

A. nothing—this is in the acceptable range.

Proper placement of the tocotransducer for electronic fetal monitoring is A. over the uterine fundus. B. on the fetal scalp. C. inside the uterus. D. over the mother's lower abdomen.

A. over the uterine fundus.

An important consideration in positioning a newborn for breastfeeding is: A. placing the infant at nipple level facing the breast. B. keeping the infant's head slightly lower than the body. C. using the forefinger and middle finger to support the breast. D. limiting the amount of areola the infant takes into the mouth.

A. placing the infant at nipple level facing the breast.

A woman weighs herself the day after delivery and is upset because she just lost 14 pounds. The nurse's best response is based on knowledge that A. pre-pregnancy weight should be reached at about 6 months. B. weight loss will increase after 48 hours. C. weight loss will occur only with diet and exercise. D. pre-pregnancy weight should be reached at about 2 weeks.

A. pre-pregnancy weight should be reached at about 6 months.

A patient who has sustained severe burns in a motor vehicle accident is starting parenteral nutrition (PN). Which principle should guide the nurse's administration of PN? A. Administration of PN requires clean technique. B. Central PN requires rapid dilution in a large volume of blood. C. Peripheral PN delivery is preferred over the use of a central line. D. Only water-soluble medications may be added to the PN by the nurse.

B. Central PN requires rapid dilution in a large volume of blood.

A newborn weighs 7 pounds 12 ounces. If he is fed regular formula 8 times a day, approximately how many ounces should he take with each feeding in order to meet his minimum requirements of kilocalories? A. 1 ounce B. 2½ ounces C. 3 ounces D. 4 ounces

B. 2½ ounces

The nurse is teaching a patient with type 1 diabetes mellitus who had surgery to revise a lower leg stump with a skin graft about nutrition. What food should the nurse teach the patient to eat to best facilitate healing? A. Nonfat milk B. Chicken breast C. Fortified oatmeal D. Olive oil and nuts

B. Chicken breast

Which focused assessments would have priority in the care of a patient recently started on parenteral nutrition (PN)? A. Skin integrity and skin turgor B. Electrolyte levels and daily weights C. Auscultation of lung and bowel sounds D. Peripheral edema and level of consciousness

B. Electrolyte levels and daily weights

A woman is 35 weeks' pregnant during her clinic visit. She complains of numerous vaginal infections during the pregnancy. She tells the nurse, "I'm afraid I have diabetes, because I have some infections." The best response by the nurse would be A. "Diabetes is a possibility. I will set you up for testing." B. "A vaginal infection is a symptom of diabetes, but it also is a problem with normal pregnancies due to the changes in your vaginal area." C. "Itching is a problem with pregnancies and it makes you think you have an infection. The physician can order you some cream to help with the itching and pain." D. "This seems to be a concern with all of our patients today."

B. "A vaginal infection is a symptom of diabetes, but it also is a problem with normal pregnancies due to the changes in your vaginal area."

The nurse has completed initial instruction with a patient regarding a weight loss program. The nurse determines that the teaching has been effective when the patient makes which statement? A. "I plan to lose 4 lb a week until I have lost the 60-lb goal." B. "I will keep a diary of weekly weights to illustrate my weight loss." C. "I will restrict my carbohydrate intake to less than 30 g/day to maximize weight loss." D. "I should not exercise more than my program requires because increased activity increases the appetite."

B. "I will keep a diary of weekly weights to illustrate my weight loss."

A 22-yr-old man is being treated at a college health care clinic for gonorrhea. What should the nurse include in patient teaching? A. "While being treated for the infection, you will not be able to pass this infection on to your sexual partner." B. "While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol." C. "It's important to complete your full course of antibiotics in order to ensure that you become resistant to reinfection." D. "The symptoms of gonorrhea will resolve on their own, but it is important for you to abstain from sexual activity while this is occurring."

B. "While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol."

A 52-yr-old man with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective? A. Negative bacterial culture B. Absence of genital lesions C. reduction of genital warts D. No drainage from chancre sore

B. Absence of genital lesions

The breastfeeding mother should be taught a safe method to remove her breast from the baby's mouth. Which suggestion by the nurse is most appropriate? A. Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. B. Break the suction by inserting your finger into the corner of the infant's mouth. C. Move the breast in the baby's mouth. D. Elicit Moro's reflex in the baby to wake the baby up and remove the breast when he cries.

B. Break the suction by inserting your finger into the corner of the infant's mouth.

A frail older adult with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. Which foods would the nurse suggest for breakfast? A. Orange juice and dry toast B. Oatmeal with butter and cream C. Waffles with fresh strawberries D. Banana and unsweetened yogurt

B. Oatmeal with butter and cream

The nurse is caring for a 45-yr-old woman with a herniated lumbar disc. The patient realizes that weight loss is necessary to lessen back strain. The patient is 5'6" tall and weighs 186 lb (84.5 kg) with a body mass index (BMI) of 28 kg/m2. The nurse explains this measurement places her in which weight category? A. Obese B. Overweight C. Severely obese D. Normal weight

B. Overweight

Which intervention lowers the risk of sudden infant death syndrome (SIDS)? A. Smoking away from the infant B. Putting the infant to sleep in the supine position C. Making sure the infant is kept very warm while sleeping D. Having the infant sleep with parents instead of alone in a crib

B. Putting the infant to sleep in the supine position

The nurse administers a Gardasil vaccine to an 18-yr-old female patient. After the injection, which patient instruction is priority? A. Avoid sexual activity for 24-48 hours B. remain lying down for at least 15 minutes C. return to the clinic in 6 months for a second dose D. use two methods of birth control to avoid pregnancy

B. Remain lying down for at least 15 minutes

The nurse administers a Gardasil vaccine to an 18-yr-old female patient. After the injection, which patient instruction is priority? A. Avoid sexual activity for 24 to 48 hours. B. Remain lying down for at least 15 minutes. C. Return to the clinic in 6 months for a second dose. D. Use two methods of birth control to avoid pregnancy.

B. Remain lying down for at least 15 minutes.

A patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of mostconcern to the nurse? A. Blood glucose level of 125 mg/dL B. Serum phosphate level of 1.9 mg/dL C. White blood cell count of 10,500/µL D. Serum potassium level of 4.6 mEq/L

B. Serum phosphate level of 1.9 mg/dL

The nurse is evaluating the nutritional status of a patient undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would best indicate the patient has protein-calorie malnutrition (PCM)? A. Serum transferrin B. Serum prealbumin C. C-reactive protein (CRP) D. Alanine transaminase (ALT)

B. Serum prealbumin

Which of these conditions may cause the fetal heart rate to be lower during labor? (Select all that apply.) A. Stimulation of the sympathetic nervous system B. Stimulation of the baroreceptors, which in turn stimulates the vagus nerve C. Prolonged hypoxia, hypercapnia, and acidosis D. Stimulation of the parasympathetic nervous system

B. Stimulation of the baroreceptors, which in turn stimulates the vagus nerve C. Prolonged hypoxia, hypercapnia, and acidosis D. Stimulation of the parasympathetic nervous system

The nurse sees a pattern on the fetal monitor that looks similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? A. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. B. This deceleration pattern is associated with utero-placental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply. C. This pattern reflects variable decelerations. No interventions are necessary at this time. D. Document this reassuring fetal heart rate pattern, but decrease the rate of the intravenous fluid.

B. This deceleration pattern is associated with utero-placental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply.

An person of Northern heritage is at an increased risk for which of the following: (Select all that apply.) A. Vitamin C deficiency B. Type 1 diabetes C. Celiac disease D. Type 2 diabetes E. Hypertension F. Metabolic syndrome

B. Type 1 diabetes C. Celiac disease

Although sexual activity is considered a normative process, some individuals place themselves at increased risk for negative consequences related to this process. Which nonsexual behavior is likely to increase risk-taking activities? A. Having multiple sexual partners B. Using alcohol, marijuana, or illicit substances C. having gay, lesbian, or bisexual partners D. Refraining from safe-sex practices such as condom use

B. Using alcohol, marijuana, or illicit substances

Why should continuous electronic fetal monitoring be used when oxytocin is administered? A. The woman may become hypotensive. B. Utero-placental exchange may be compromised. C. Maternal fluid volume deficit may occur. D. Fetal chemoreceptors are stimulated.

B. Utero-placental exchange may be compromised.

A patient who cannot afford enough food for her family states she only eats after her children have eaten. At a clinic visit, she reports bleeding gums; loose teeth; and dry, itchy skin. Which vitamin deficiency would the nurse suspect? A. Folic acid B. Vitamin C C. Vitamin D D. Vitamin K

B. Vitamin C

A woman in active labor and has been admitted to the birthing unit. She calls the nurse and says her "water just broke." The first nursing action should be A. change the pad under the woman to keep her dry and comfortable. B. assess the fetal heart rate for 1 minute. C. assess the maternal vital signs. D. notify the nurse-midwife.

B. assess the fetal heart rate for 1 minute.

During an assessment, the nurse notes that the fetus is in complete flexion, with the head flexed toward the chest and the arms and legs flexed over the thorax. The fetal back is curved in a convex shape. This is termed fetal A. lie. B. attitude. C. presentation. D. passage.

B. attitude.

The best measure to prevent abdominal distention following a cesarean birth is A. rectal suppositories. B. early and frequent ambulation. C. tightening and relaxing abdominal muscles. D. carbonated beverages.

B. early and frequent ambulation.

The role of the nurse in family planning is to A. advise couples on which contraceptive to use. B. educate couples on the various methods of contraception. C. decide on the best method for the couple. D. refer the couple to a reliable physician.

B. educate couples on the various methods of contraception.

A woman is admitted to the birthing unit in labor. Upon assessment, it is noted that she is 3 cm dilated and 80% effaced with intact membranes. The nurse understands that her fetal monitoring will be done by A. internal electrodes. B. external electrode.

B. external electrode.

Pregnant women can usually tolerate the normal blood loss associated with childbirth because they have A. a higher hematocrit. B. increased blood volume. C. a lower fibrinogen level. D. increased leukocytes.

B. increased blood volume.

The nurse should include in patient teaching that around day four the lochia should be A. dark red. B. pinkish. C. cream-colored. D. disappearing or gone.

B. pinkish.

A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the ophthalmic ointment is to A. destroy an infectious exudate caused by Staphylococcus that could make the infant blind. B. prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. C. prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. D. prevent the infant's eyelids from sticking together and help the infant see.

B. prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.

What is the first step in assisting the breastfeeding mother? A. Provide instruction on the composition of breast milk. B. Discuss the hormonal changes that trigger the milk ejection reflex. C. Assess the woman's knowledge of breastfeeding. D. Help her obtain a comfortable position, and place the infant to the breast.

C. Assess the woman's knowledge of breastfeeding.

A woman calls the nurse at the clinic stating, "I forgot to take my birth control pill this morning before I left for work. What should I do?" The nurse's answer should be based on the knowledge that A. the woman should use another form of birth control until she completes a new cycle of pills. B. the woman should take the one missed pill as soon as possible and the next pill at the regular scheduled time. She will not need back-up contraception. C. the woman should take two pills as soon as possible and then continue on with the regular schedule. She will also need to use a back-up contraceptive method. D. the woman should wait until withdrawal bleeding and then start on her next cycle of pills; she will need to use a backup contraceptive method.

B. the woman should take the one missed pill as soon as possible and the next pill at the regular scheduled time. She will not need back-up contraception.

A 19-yr-old man comes to the outpatient clinic for treatment of uncomplicated gonorrhea. Which patient statement requires immediate clarification by the nurse? A. "I should avoid alcohol intake for at least 2 weeks." B. "I will have my sexual partner come in for treatment." C. "After I start the antibiotic, it is safe to have sex again." D. "After the treatment, I do not need to return to the clinic for retesting."

C. "After I start the antibiotic, it is safe to have sex again."

The parents of a newborn infant state, "We will probably not have our baby immunized because we are concerned about the risks." What is the nurse's best response? A. "It is your decision to immunize your child or not." B. "You should probably think about this decision." C. "It is far riskier to not immunize your baby." D. "This has to be reported to the health department."

C. "It is far riskier to not immunize your baby."

A woman who is 7 months' pregnant states, "I'm worried that something will happen to my baby." The nurse's best response is A. "There is nothing to worry about." B. "The doctor is taking good care of you and your baby." C. "Tell me about your concerns." D. "Your baby is doing fine."

C. "Tell me about your concerns."

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans' sign and asks what it means. The nurse's best response is A. "You have pitting edema in your ankles." B. "You have deep tendon reflexes rated 2+." C. "You have calf pain when the nurse flexes your foot." D. "You have a fleshy odor to your vaginal drainage."

C. "You have calf pain when the nurse flexes your foot."

How many ounces will a formula-fed infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs? A. 0.5 to 1 B. 1 to 2 C. 2 to 3 D. 4

C. 2 to 3

In developing a weight reduction program with a 45-yr-old female patient who weighs 197 lb, the nurse encourages the patient to set a weight loss goal of how many pounds in 4 weeks? A. 1 to 2 B. 3 to 5 C. 4 to 8 D. 5 to 10

C. 4 to 8

A newborn weighed 7 pounds 8 ounces at birth. What is the lowestweight that he can reach and still be within the expected range of weight loss? A. 6 pounds B. 6 pounds 8 ounces C. 6 pounds 12 ounces D. 7 pounds

C. 6 pounds 12 ounces

Despite the importance of sexual health to overall well-being, many nurses and patients are uncomfortable discussing issues related to sexuality. It is for this reason that the nurse must include questions regarding a sexual health history as part of a comprehensive health assessment. A 15-year-old female patient has come to the office for her annual physical and first pelvic examination. In this situation, which nursing action is most important? A. Encourage the patient to ask questions about sexuality B. Screen for possible abuse C. Excuse the parent D. Ensure the patient that all information will be kept confidential

C. Excuse the parent

A patient who has dysphagia after a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into the plan of care? A. Use 30 mL of normal saline to flush the tube every 4 hours. B. Avoid flushing the tube any time the patient is receiving continuous feedings. C. Flush the tube before and after feedings if the patient's feedings are intermittent. D. Flush the PEG with 100 mL of sterile water before and after medication administration.

C. Flush the tube before and after feedings if the patient's feedings are intermittent.

In order to fully understand the concept of sexuality, it is necessary to become familiar with the terms used when discussing this topic. Which term best describes how one views oneself as masculine or feminine? A. Sexual Identity B. Sexual orientation C. Gender Identity D. Sexual Behavior

C. Gender identity

A 24-yr-old patient is at the clinic with symptoms of purulent vaginal discharge, dysuria, and dyspareunia. She is sexually active and has multiple partners. What should the nurse explain as the rationale for Chlamydia screening? A. Chlamydia is frequently comorbid with HIV B. Chlamydial infections may progress to sepsis C. Untreated chlamydial infections can lead to infertility D. Chlamydial infections are treatable only in the early stages of infection

C. Untreated chlamydial infections can lead to infertility

A 24-yr-old patient is at the clinic with symptoms of purulent vaginal discharge, dysuria, and dyspareunia. She is sexually active and has multiple partners. What should the nurse explain as the rationale for Chlamydia screening? A. Chlamydia is frequently comorbid with HIV. B. Chlamydial infections may progress to sepsis. C. Untreated chlamydial infections can lead to infertility. D. Chlamydial infections are treatable only in the early stages of infection.

C. Untreated chlamydial infections can lead to infertility.

The history and physical of a 29-yr-old female patient are indicative of human papillomavirus (HPV) infection. What treatment option should be discussed with the patient? A. Gardasil B. Antibiotic therapy C. Wart removal options D. Treatment with antiviral drugs

C. Wart removal options

During a postpartum teaching session concerning contraception, the woman states she will continue to use her diaphragm she has had for 2 years. The best response by the nurse should be based on the fact that A. diaphragms are a good contraceptive choice during the early postpartum period. B. diaphragms should not be used during the late postpartum period. C. diaphragms should be refitted after the birth of a baby. D. diaphragms are not effective if the mother is breastfeeding.

C. diaphragms should be refitted after the birth of a baby.

The nurse is timing her patient's contractions. The following pattern occurs: Contraction starts: 7:32 Contraction ends: 7:32 (lasts 30 seconds) Contraction starts: 7:37 Contraction ends: 7:38 (lasts 30 seconds) Contraction starts: 7:42 Contraction ends: 7:42 (lasts 30 seconds) The nurse records the frequency of the contraction as A. every 4 to 5 minutes. B. lasting 30 seconds. C. every 5 minutes. D. lasting 30 seconds to 1 minute.

C. every 5 minutes.

A woman tells the nurse she is 16 weeks' pregnant. During the assessment, the nurse measures the fundus of the uterus to be at the umbilicus. The nurse correctly interprets the comparison of the dates with the measurements to be A. not comparable. B. congruent. C. incongruent. D. irrelevant.

C. incongruent.

To evaluate the woman's learning about performing infant care, the nurse should A. demonstrate infant care procedures. B. allow the woman to verbalize the procedure. C. observe the woman as she performs the procedure. D. routinely assess the infant for cleanliness.

C. observe the woman as she performs the procedure.

The situation that best describes secondary infertility is a couple who has A. never conceived. B. had repeated spontaneous abortions. C. one child but has not been able to conceive a second time. D. not conceived after 1 year of unprotected intercourse.

C. one child but has not been able to conceive a second time.

The best distinction between true labor and false labor is the A. increase in frequency of contractions. B. increase in pain with contractions. C. progressive changes in the cervix.

C. progressive changes in the cervix.

When comparing colostrum with mature breast milk, colostrum has higher amounts of A. calories, fat, and lactose. B. protein, calories, and fat. C. protein, fat-soluble vitamins, and minerals. D. fat, fat-soluble vitamins, and minerals.

C. protein, fat-soluble vitamins, and minerals.

Infants born before surfactant production are at risk for A. temperature instability. B. cardiovascular difficulties. C. respiratory distress syndrome. D. jaundice.

C. respiratory distress syndrome.

After monitoring the fetal heart rate for 10 minutes, the nurse notices the rate is staying at 175 bpm. The nurse is correct in classifying this baseline rate as A. normal. B. bradycardia. C. tachycardia. D. acceleration.

C. tachycardia.

During labor, the nurse is aware that the woman's vital signs are best assessed between contractions. The rationale for this is that A. the mother is more comfortable and will comply. B. the pain of the contractions will alter her vital signs. C. the contractions decrease blood flow to the placenta, therefore increasing the woman's blood volume and altering her vital signs. D. it is impossible to hear the fetal heart rate through the contracted muscles of the uterus.

C. the contractions decrease blood flow to the placenta, therefore increasing the woman's blood volume and altering her vital signs.

During a teaching session of college students, the nurse explains that the student health clinic has emergency contraceptives available. One topic of teaching that is important to include in the teaching concerning the use of emergency contraceptives is: A. it is important the woman not douche after unprotected intercourse and prior to being seen at the health clinic. B. the woman must start the emergency contraceptives only within 2 hours of unprotected intercourse to be 100% effective. C. the woman must start the emergency contraceptives within 72 hours of unprotected intercourse. D. the woman must wait until the first day of her missed period before starting the emergency contraceptives.

C. the woman must start the emergency contraceptives within 72 hours of unprotected intercourse.

A 36-year-old comes to the clinic requesting contraception. She presents with a history of hypertension (now under control with treatment) and a past history of pelvic inflammatory disease. She smokes one pack of cigarettes a day and admits to having "numerous" sexual partners. Which contraceptive method is appropriate for her? A. Oral contraceptives B. Transdermal contraceptive patch C. Intrauterine device D. Condoms

D. Condoms

The nurse obtains a history from a 34-yr-old woman diagnosed with a chlamydial infection. Which patient statement indicates additional teaching is required? A. "This infection can be cured by taking antibiotics." B. "It is important to use condoms for all sexual activity." C. "I will avoid sexual contact for 1 week after taking the antibiotics." D. "My sexual partner does not have symptoms and will not need treatment."

D. "My sexual partner does not have symptoms and will not need treatment."

A postpartum woman asks, "Will these stretch marks go away?" The nurse's best response is A. "They will continue to fade and should be gone by your 6-week checkup." B. "No, never." C. "Yes, eventually." D. "They will fade to silvery lines but won't disappear completely."

D. "They will fade to silvery lines but won't disappear completely."

The severely obese patient has elected to have the Roux-en-Y gastric bypass (RYGB) procedure. The nurse will know the patient understands the preoperative teaching when the patient makes which statement? A. "This surgery will preserve the function of my stomach." B. "This surgery will remove the fat cells from my abdomen." C. "This surgery can be modified whenever I need it to be changed." D. "This surgery decreases how much I can eat and how many calories I can absorb."

D. "This surgery decreases how much I can eat and how many calories I can absorb."

Which patient is at risk for developing metabolic syndrome? A. A 62-yr-old white man who has coronary artery disease with chronic stable angina B. A 54-yr-old Hispanic woman who is sedentary and has nephrogenic diabetes insipidus C. A 27-yr-old Asian American woman who has preeclampsia and gestational diabetes mellitus D. A 38-yr-old Native American man who has diabetes mellitus and elevated hemoglobin A1C

D. A 38-yr-old Native American man who has diabetes mellitus and elevated hemoglobin A1C

Which event discovered during pregnancy would alert the nurse that a cesarean section delivery is indicated? A. Contact with an individual with syphilis 2 weeks ago B. Treatment for gonococcal pharyngitis before conception C. Treatment for Chlamydia trachomatis at her 20th week of gestation D. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

D. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

Which event discovered during pregnancy would alert the nurse that a cesarean section delivery is indicated? A. Contact with an individual with syphilis 2 weeks ago B. Treatment for gonococcal pharyngitis before conception C. Treatment for Chlamydia trachomatis at her 20th week of gestation D. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

D. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

The nurse is reviewing the laboratory test results for a patient with metastatic lung cancer who was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. How will the nurse interpret these results? A. The albumin level is normal therefore the patient does not have protein malnutrition. B. The albumin level is increased, which is common in patients with cancer who have malnutrition. C. Both the serum albumin and prealbumin levels are reduced, consistent with the diagnosis of malnutrition. D. Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

D. Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

The infant of a diabetic mother is hypoglycemic. What type of feeding should be instituted first? A. Glucose water in a bottle B. D5W intravenously C. Formula via nasogastric tube D. Breastfeeding, or breast milk/formula in a bottle

D. Breastfeeding, or breast milk/formula in a bottle

A 30-yr-old woman reports the recent appearance of itchy lesions on her vulva, some of which have recently burst. Which STI should the nurse suspect first? A. HIV B. Gonorrhea C. Chlamydia D. genital herpes

D. Genital herpes

A 30-yr-old woman reports the recent appearance of itchy lesions on her vulva, some of which have recently burst. Which STI should the nurse suspect first? A. HIV B. Gonorrhea C. Chlamydia D. Genital herpes

D. Genital herpes

While the vital signs of a pregnant woman in her third trimester are being assessed, the woman, who is lying supine, complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? A. Have the patient stand up; retake her blood pressure. B. Have the patient sit down and hold her arm in a dependent position. C. Have the patient lie supine for 5 minutes; recheck her blood pressure on both arms. D. Have the patient turn to her left side; recheck her blood pressure in 5 minutes.

D. Have the patient turn to her left side; recheck her blood pressure in 5 minutes.

How can the nurse help the mother who is nursing and has engorged breasts? A. Suggest that she switch to bottled formula just for today. B. Assist her to remove her bra, making her more comfortable. C. Apply heat to her breasts between feeding and cold to the breasts just before feedings. D. Instruct and assist the mother to massage her breasts.

D. Instruct and assist the mother to massage her breasts.

Which maternal event is abnormal in the early postpartal period? A. Diuresis and diaphoresis B. Flatulence and constipation C. Increased hunger and thirst D. Lochial color changes from rubra to alba

D. Lochial color changes from rubra to alba

A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Irrigate the tube between feedings. B. Provide wound care at the gastrostomy site. C. Administer prescribed liquid medications through the tube. D. Position the patient with a 45-degree head of bed elevation.

D. Position the patient with a 45-degree head of bed elevation.

Human sexuality is interrelated with a variety of other nursing concepts that may affect sexuality or be affected by healthy sexual functioning. Prompt diagnosis and treatment of potential concerns related to concept overlap is an important nursing function. Which other concept is most likely to overlap with sexuality? A. Stress B. Gas exchange C. Pain D. Reproduction

D. Reproduction

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? A. Delayed growth and development B. Ineffective thermoregulation C. Ineffective infant feeding pattern D. Risk for infection

D. Risk for infection

The woman complains that the afterpains are worse after this baby than after her first child. The nurse's best response would be that A. afterbirth pains should be the same unless the uterus is boggy. B. afterbirth pains should be the same unless the bladder is full. C. afterbirth pains should be easier with each pregnancy. D. afterbirth pains increase in intensity with each pregnancy.

D. afterbirth pains increase in intensity with each pregnancy.

During a prenatal visit at 36 weeks of gestation, the nurse tested a woman's urine for glucose and protein. The results indicated a trace amount of glucose. The nurse's next action should be to A. retest the urine for accuracy. B. have the woman give another sample for retesting. C. report the results immediately to the physician so further testing can be preformed. D. consider this as a normal result for this stage of pregnancy.

D. consider this as a normal result for this stage of pregnancy.

When preparing a woman for a pelvic examination, the nurse notices that she had undergone a genital mutilation. During the examination, the nurse needs to plan for the woman to A. feel embarrassed because of the mutilation. B. be comfortable with the examination. C. be concerned that a full examination will not be possible. D. experience pain and to make her as comfortable as possible.

D. experience pain and to make her as comfortable as possible.

The new mother is taught to continue feeding on one breast until empty in order for the infant to get the hindmilk. One advantage of the infant receiving sufficient amounts of hindmilk is that it contains A. the majority of immunoglobulins. B. higher amounts of protein. C. lower amounts of cholesterol. D. higher amounts of fat.

D. higher amounts of fat.

A primiparous woman wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant A. with his arms folded together over his chest. B. curled up in a fetal position. C. with his head cupped in her hand. D. with his head and body in alignment.

D. with his head and body in alignment.

In assessing patients for STIs, the nurse needs to know that many STIs can be asymptomatic. Which STIs can be asymptomatic (select all that apply)? a. Syphilis b. Gonorrhea c. Genital warts d. Genital herpes e. Chlamydial infection

a. Syphilis b. Gonorrhea c. Genital warts d. Genital herpes e. Chlamydial infection

The nurse is obtaining a subjective data assessment from a woman reported as a sexual contact of a man with chlamydial infection. The nurse understands that symptoms of chlamydial infection in women a. are frequently absent. b. are similar to those of genital herpes. c. include a macular palmar rash in the later stages. d. may involve chancres inside the vagina that are not visible.

a. are frequently absent.

Which method is best to use when confirming initial placement of a blindly inserted small-bore NG feeding tube? a. x-ray. b. air insufflation. c. observing patient for coughing. d. pH measurement of gastric aspirate.

a. x-ray.

What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy? a. Average for gestational age, term b. Small for gestational age, preterm c. Large for gestational age, post term d. Large for gestational age, near term

d. Large for gestational age, near term

The nurse is educating a group of adolescents on sexuality and health. The nurse decided to include primary prevention strategies as topic for discussion. Which intervention is considered a primary prevention strategy? a. Encouraging HIV testing after unprotected sex b. Teaching about sexual dysfunction c. Diagnosing HPV at an early stage d. Teaching the correct use of condoms

d. Teaching the correct use of condoms

A 17-year-old female patient tells the nurse that she believes she was born the wrong gender ad feels lie she is a male inside. The nurse knows that this statement indicates which sexual orientation: a. The patient is a lesbian b. The patient is bisexual c. The patient is questioning her sexuality d. The patient is transgender

d. The patient is transgender

The obesity classification that is most often associated with cardiovascular health problems is a. primary obesity. b. secondary obesity. c. gynoid fat distribution. d. android fat distribution.

d. android fat distribution.

The best nutritional therapy plan for a person who is obese is a. the Zone diet. b. the Atkins diet. c. Sugar Busters. d. foods from the basic food groups.

d. foods from the basic food groups.

A 22-yr-old man is being treated at a college health care clinic for gonorrhea. What should the nurse include in patient teaching? A. While being treated for the infection, you will not be able to pass this infection on to your sexual partner." B. "While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol." C. "It's important to complete your full course of antibiotics in order to ensure that you become resistant to reinfection." D. "The symptoms of gonorrhea will resolve on their own, but it is important for you to abstain from sexual activity while this is occurring."

While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol."

The percentage of daily calories for a healthy person consists of a. 50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids. b. 65% carbohydrates, 25% protein, 25% fat, and >10% of fat from saturated fatty acids. c. 50% carbohydrates, 40% protein, 10% fat, and <10% of fat from saturated fatty acids. d. 40% carbohydrates, 30% protein, 30% fat, and >10% of fat from saturated fatty acids.

a. 50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids.

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include? a. Assessing respirations, keeping him warm, and identifying him b. Applying an antibiotic to the eyes, administering vitamin K, and bathing him c. Aspirating the oropharynx, rushing him to the nursery, and stimulating him often d. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him

a. Assessing respirations, keeping him warm, and identifying him

A female patient comes to the clinic at 8 weeks' gestation. She lives in a house beneath electrical power lines, which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest impact for this patient's plan of care? a. Drinking alcohol should be avoided during pregnancy because of its teratogenic effects b. Eating sweets may cause gestational diabetes or miscarriage c. Electrical power lines are potential hazard to the woman and her fetus d. Living near an oil field may mean the water supply is polluted

a. Drinking alcohol should be avoided during pregnancy because of its teratogenic effects

Which criteria must be met for a diagnosis of metabolic syndrome (select all that apply)? a. Hypertension b. Elevated triglycerides c. Elevated plasma glucose d. Increased waist circumference e. Decreased low-density lipoproteins

a. Hypertension b. Elevated triglycerides c. Elevated plasma glucose d. Increased waist circumference

A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? (TORCH, which includes Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections, are some of the most common infections associated with congenital anomalies.) a. In utero thought the placenta b. In the postpartum period through breast milk c. During birth through contact with the maternal vagina d. After the birth through a blood transfusion given to the mother

a. In utero thought the placenta

Two days after having a cesarean birth, a client tells the nurse that she has pain in her right leg. After an assessment the nurse suspects that the client has a thrombus. What is the nurse's primary response at this time? a. Maintaining bed rest b. Applying warm soaks c. Performing leg exercises d. Massaging the affected area

a. Maintaining bed rest

A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, how does the nurse identify them? a. Milia b. Languo c. White heads d. Mongolian spots

a. Milia

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action? a. Notifying the health care provider b. Resuming continuous fetal heart monitoring c. Continuing to monitor the maternal vital signs d. Documenting the fetal heart rate as an expected response to contractions

a. Notifying the health care provider

You are working with a college student who is planning to become sexually active. She is requesting a reliable method of birth control that could be easily discontinued if necessary. Which option should be given the strongest recommendation? a. Oral contraceptive pills b. Natural family planning c. Coitus interruptus d. Intrauterine device (IUD)

a. Oral contraceptive pills

A patient with anorexia nervosa shows signs of malnutrition. During initial refeeding, the nurse carefully assesses the patient for a. hyperkalemia. b. hypoglycemia. c. hypercalcemia. d. hypophosphatemia.

d. hypophosphatemia.

2. Place in order the substrates the body uses for energy during starvation, beginning with 1 for the first component and ending with 4 for the last component. a. skeletal protein. b. glycogen. c. visceral protein. d. fat stores.

b, a, d, c

A patient is receiving peripheral parenteral nutrition. The parenteral nutrition solution is completed before the new solution arrives on the unit. The nurse gives a. 20% intralipids. b. 5% dextrose solution. c. 0.45% normal saline solution. d. 5% lactated Ringer's solution.

b. 5% dextrose solution.

A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure od 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? a. Increasing the infusion rate b. Checking for a distended bladder c. Continuing to perform fundal massage d. Continuing to assess the blood pressure

b. Checking for a distended bladder

A neonate begins to exhibit nasal flaring and grunting at 16 hours of age. What is the nurse's initial action? a. Administering vitamin K b. Elevating the head of the crib c. Hyperextending the infant's head d. Covering the infant with another blanket

b. Elevating the head of the crib

A preterm neonate is receiving oxygen by way of an overhead hood. Which nursing interventions should the nurse implement to protect the infant under the oxygen hood? a. Offer fluid every 15 minutes to prevent dehydration b. Put a hat on the infant's head to prevent hypothermia c. Keep the oxygen concentration consistent to limit respiratory distress d. Remove the infant from the hood every 15 minutes to provide stimulation

b. Put a hat on the infant's head to prevent hypothermia

When a client at 39 weeks' gestation arrives at the birthing suites she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse's action be to confirm that the membranes have ruptured? a. Take the client's oral temperature. b. Test the leaking fluid with Nitrazine paper c. Obtain a clean-catch urine specimen d. Inspect the perineum for leaking fluid

b. Test the leaking fluid with Nitrazine paper

The nurse in the family planning clinic is developing a teaching plan for a 22-year-old woman who was treated for pelvic inflammatory disease. What information should the nurse include in the plan of care? a. The importance of calculating monthly period b. The increased risk of infertility c. The possibility of changes in secondary sex characteristics d. The need to take the birth control pill

b. The increased risk of infertility

The nurse assures a breast-feeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested? a. Has several firm stools daily b. Voids six or more times a day c. Spits out a pacifier when offered d. Awakens to feed about every 4 hours

b. Voids six or more times a day

The individual with the lowest risk for sexually transmitted pelvic inflammatory disease is a woman who uses a. oral contraceptives. b. barrier methods of contraception. c. an intrauterine device for contraception. d. Norplant implant or injectable Depo-Provera for contraception.

b. barrier methods of contraception.

Provide emotional support to a patient with an STI by a. offering information on how safer sexual practices can prevent STIs. b. showing concern when listening to the patient who expresses negative feelings. c. reassuring the patient that the disease is highly curable with appropriate treatment. d. helping the patient who received an STI from his or her sexual partner in forgiving the partner.

b. showing concern when listening to the patient who expresses negative feelings.

A primary HSV infection differs from recurrent HSV episodes in that (select all that apply) a. only primary infections are sexually transmitted. b. symptoms are less severe during recurrent episodes. c. transmission of the virus to a fetus is less likely during primary infection. d. systemic manifestations such as fever and myalgia are more common in primary infection. e. lesions from recurrent HSV are more likely to transmit the virus than lesions from primary HSV.

b. symptoms are less severe during recurrent episodes. d. systemic manifestations such as fever and myalgia are more common in primary infection.

A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first time. After the physical examination she tells the nurse, "I can't believe how big I am. Will I get much bigger?" what information about adolescent growth and development does the nurse need to know to understand before responding? a. Adolescents generally regain their figures 2 weeks after the birth, so size is of moderate concern. b. Adolescents are in a high-risk category, so weight gain should be limited to prevent complications. c. Body image is very important to adolescents; therefore pregnant teenagers are overly concerned about body size. d. Physiological growth in adolescents is more rapid than in adults, so the gravid size is larger than that of an adult woman.

c. Body image is very important to adolescents; therefore pregnant teenagers are overly concerned about body size.

The nurse is taking a health history of a 56-year-old male patient. He tells the nurse that he and his wife just got a divorce over 1 month ago, and he is now dating multiple women. He states that he is sexually active again after 2 months of abstinence during his divorce. The nurse know that teaching should include: a. The patient should not bother getting tested for STIs. STIs usually only occurring the adolescent age group b. Longer periods of foreplay may be necessary before sexual intercourse now that the patient is I his fifties c. Condoms should always be used during sexual activity d. Because the patient is in his fifties, impotence could be an issue. The patient should not use condoms

c. Condoms should always be used during sexual activity

The nurse is working with a couple in the infertility clinic. Which of the following should the nurse include in the teaching plan? a. Keep track of the number of times they have sex b. Determine the time of menstruation c. Determine the estimated time of ovulation d. Avoid intercourse before the appointments

c. Determine the estimated time of ovulation

The nurse is obtaining a sexual history of a 28-year-old woman. Which of the following questions is most useful in determining the patient's sexual orientation and risk factors? a. How many partners have you had? b. Do you prefer to have sex with men or women? c. Have you had sex with men, women, or both? d. Are you heterosexual, homosexual, or bisexual?

c. Have you had sex with men, women, or both?

Which statement best describes the etiology of obesity? a. Obesity primarily results from a genetic predisposition. b. Psychosocial factors can override the effects of genetics in the etiology of obesity. c. Obesity is the result of complex interactions between genetic and environmental factors. d. Genetic factors are more important than environmental factors in the etiology of obesity.

c. Obesity is the result of complex interactions between genetic and environmental factors.

A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.8 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response? a. "You have not gained enough weight. Can you increase your daily intake of calories?" b. "Your weight is not a concern. I'll refer you to the dietitian, who will review your diet." c. "You've gained too much weight for 23 weeks' gestation. Are your rings getting tight?" d. "Your weight is expected for someone at 23 weeks' gestation. Continue your current diet."

d. "Your weight is expected for someone at 23 weeks' gestation. Continue your current diet."

This bariatric surgical procedure involves creating a gastric pouch that is reversible and no malabsorption occurs. What surgical procedure is this? a. Vertical gastric banding b. Biliopancreatic diversion c. Roux-en-Y gastric bypass d. Adjustable gastric banding

d. Adjustable gastric banding

A married couple present to the preconceptual clinic with questions about how a fetus's chromosomal sex is established. What is the nurse's best response? a. At ovulation, chromosomal sex is established b. At ejaculation, chromosomal sex is established c. At climax, chromosomal sex is established d. At fertilization, chromosomal sex is established

d. At fertilization, chromosomal sex is established

The nurse is assessing a term newborn. Which sign should the nurse report to the pediatric primary healthcare provider? a. Temperature of 97.7° F (36.5° C) b. Pale-pink to rust-colored stain in the diaper c. Heart rate that decreases to 115 beats/min d. Breathing pattern with recurrent sternal retractions

d. Breathing pattern with recurrent sternal retractions

One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next? a. Encourage the client to void b. Notify the practitioner immediately c. Massage the uterus and attempt to express clots d. Continue periodic assessments and record findings

d. Continue periodic assessments and record findings

When changing her newborn's diaper, a new mother notes a reddened area on the infant's buttock and reports it to the nurse. How should the nurse best address this mother's concern? a. Have nursery staff members change the infant's diaper. b. Use both lotion and powder to protect the involved area. c. Request that the health care provider prescribe a topical ointment. d. Encourage the mother to cleanse the area and change the diaper more often.

d. Encourage the mother to cleanse the area and change the diaper more often.

5. An infant born with hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home? a. Visibility of the sclerae above the irises b. Violent involuntary muscle contractions c. Excessive fluid accumulation in the abdomen d. Fever accompanied by decreased responsiveness

d. Fever accompanied by decreased responsiveness

A 20-year-old woman comes for preconceptual counseling. She wants to get pregnant soon. Which of the following health-promoting habits would have the highest priority at this time? a. Stopping all caffeine b. Avoidance of sweets c. Getting daily exercise d. Immediate tobacco cessation

d. Immediate tobacco cessation

A patient with extreme obesity has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient a. may have severe diarrhea early in the postoperative period. b. will not be allowed to ambulate for 1 to 2 days postoperatively. c. will require nasogastric suction until the drainage is pale yellow. d. may have only liquids orally, and in very limited amounts, during the early postoperative period.

d. may have only liquids orally, and in very limited amounts, during the early postoperative period.

A complete nutritional assessment including anthropometric measurements is most important for the patient who a. has a BMI of 25.5 kg/m2. b. complains of frequent nocturia. c. reports a 5-year history of constipation. d. reports an unintentional weight loss of 10 lb in 2 months.

d. reports an unintentional weight loss of 10 lb in 2 months.

To prevent the infection and transmission of STIs, the nurse's teaching plan would include an explanation of a. the appropriate use of oral contraceptives. b. sexual positions that can be used to avoid infection. c. the necessity of annual Pap tests for patients with HPV. d. sexual practices that are considered high-risk behaviors.

d. sexual practices that are considered high-risk behaviors.

Explain to the patient with gonorrhea that treatment will include both ceftriaxone and azithromycin because a. azithromycin helps prevent recurrent infections. b. some patients do not respond to oral drugs alone. c. coverage with more than one antibiotic will prevent reinfection. d. the increasing rates of drug resistance requires the use of at least two drugs.

d. the increasing rates of drug resistance requires the use of at least two drugs.