EAQ NCLEX questions

A woman has made the decision to have breast augmentation surgery, and the procedure is to be performed on an outpatient basis. As part of the preoperative protocol, the nurse provides teaching regarding the discharge instructions. Which instructions apply to this type of surgery? Select all that apply. 1. "Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief." 2. "Sleep with your head and torso elevated for at least 1 week." 3. "Sleep on your back or sides but not on your stomach." 4. "Begin slowly raising your arms over your head after the first week." 5. "Take your temperature daily and notify the clinic if it goes above 99.6° F."

1. "Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief." , 2. "Sleep with your head and torso elevated for at least 1 week.", 5. "Take your temperature daily and notify the clinic if it goes above 99.6° F." Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided because of their anticoagulant effects. Elevating the head and torso will reduce edema at the surgical site. This is necessary to help identify the presence of infection. The side-lying position may be traumatic to the surgical area; the client should sleep on her back. Raising the arms above the head may cause movement of the pectoralis muscle and could result in trauma to the surgical area; the arms should not be raised above the head for at least 3 weeks.

The nurse is caring for a couple during their initial visit to a fertility clinic after being unable to conceive for 2 years. Which of the following assessment questions would be appropriate to determine an alternate cause of infertility? 1. "Do you use any lubrication during intercourse?" 2. "Can both of you reach orgasm at the same time?" 3."What type of birth control did you use in the past?" 4."Are you consistent in the manner in which you have intercourse?"

1. "Do you use any lubrication during intercourse?" Rationale: Some lubricants act as a spermicide; they should be avoided, or only a recommended one should be used. A female orgasm is not necessary for conception; simultaneous orgasms is not relevant. The type of birth control used 2 years before the couple began trying to conceive is not relevant at this time; some hormonal contraceptives should be discontinued 6 to 18 months before trying to conceive. Consistency in the manner of intercourse usually is not relevant to conception, although a change in position may be recommended.

A male infant born at 35 weeks' gestation is in the neonatal intensive care unit (NICU). When the mother is told that her infant's condition is now stable, she asks, "When will I be able to breastfeed my son?" How should the nurse respond? 1. "Even though he's preterm, his condition is stable. You may try now, if you like." 2. "Preterm infants shouldn't breastfeed. It takes more energy than formula feeding." 3. "Pump your breasts now, and then feed him the milk in a bottle with a preemie nipple." 4. "Because he's preterm and sucks weakly, it'll be several weeks before you'll be able to breastfeed."

1. "Even though he's preterm, his condition is stable. You may try now, if you like." Rationale: A preterm infant may have a weak suck but usually can be breastfed; the mother should attempt it if the infant's condition is stable. It does not necessarily take more calories to breastfeed; also, there are immunological benefits for the preterm infant who is receiving antibodies from breast milk. Pumping the breasts may be necessary, but at 35 weeks if the infant is stable and the mother so desires, breastfeeding may be attempted. The suck may or may not be weak, but a supervised attempt to breastfeed should be encouraged.

On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. How should the nurse respond? 1. "It seems that you've changed your mind about rooming in." 2. "I think you're having difficulty caring for the baby." 3. "All right. I'll inform the other nurses of your decision." 4. "You must be tired. I'll bring the baby back at feeding time."

1. "It seems that you've changed your mind about rooming in." Rationale: Stating that it seems that the client has changed her mind opens communication and allows the client to verbalize her thoughts and feelings. Stating that the client is having difficulty caring for the baby is judgmental; there is not enough information for the nurse to make this assumption. Stating the intention of informing the other nurses of the client's decision does not give the client the opportunity to verbalize her feelings and needs. Stating that the client must be tired ignores the client's needs and cuts off communication.

What instruction should a nurse include when teaching about the correct use of a female condom? 1. "Remove the condom before standing up." 2. "Insert the condom within 1 hour before intercourse." 3. "Have your partner wear a male condom at the same time." 4. "Cleanse the condom with warm water when preparing it for future use."

1. "Remove the condom before standing up." Rationale: Removing the condom before standing up keeps the semen in the female condom and prevents the inadvertent contact of semen with vaginal tissues. The female condom may be inserted as long as 8 hours before intercourse. Having the partner wear a male condom at the same time is unnecessary; this will increase friction that could tear the female condom. Female condoms should be used once and discarded.

A 16-year-old girl at 28 weeks' gestation arrives at the prenatal clinic with her mother for a routine sonogram. Before the procedure, the girl asks that the nurse not reveal the fetus's sex if it should become apparent. Afterward, the mother asks the nurse the sex of the fetus. In light of the mother-daughter relationship, the best response by the nurse is: 1. "That information is not available at this time." 2. "I'm not allowed to divulge confidential information." 3. "Your daughter asked me not to give that information to anyone." 4. "The sex of the baby isn't the most important information at this time."

1. "That information is not available at this time." Rationale: Stating that the information is not available at this time supports the client's right to confidentiality without antagonizing the client's mother. Stating that the sex of the baby isn't the most important information at this time is a judgmental, nontherapeutic statement. Although the other responses protect the client's right to confidentiality, they could disrupt the relationship between the client and her mother.

When a client who had a mastectomy sees her incision for the first time, she exclaims, "I look horrible! Will it ever look better?" What is the nurse's best response? 1. "You seem shocked by the way you look now." 2. "Now that the tumor is gone, the area will heal quickly." 3. "After it heals, others won't even know you had surgery." 4. "You will feel better about it when the swelling subsides."

1. "You seem shocked by the way you look now" Rationale: Reflection of feelings provides an opportunity to express emotions, which may promote eventual acceptance of body image changes. Saying that the area will heal quickly now that the tumor is gone, that others won't know that the client had surgery, or that the client will feel better once the swelling subsides negates the client's feelings and is not an honest or realistic response; false reassurance does not promote trust.

By how much should the nurse instruct a pregnant client to increase her daily protein intake? 1. 10 g 2. 20 g 3. 30 g 4. 40 g

1. 10 g Rationale: Ten grams is the amount of increase in the daily protein intake recommended for pregnant women by the Food and Nutrition Board of the National Academy of Sciences. Twenty, 30, and 40 g are all more than the recommended amount, although most women in developed countries exceed the requirement.

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain: 1. Abduction 2. Adduction 3.Traction 4. Elevation

1. Abduction Rationale: Abduction means to move the limb away from the median plane, or axis, of the body. In care of the client with a fractured hip, the legs and hip must be aligned in an abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain. In a client with a fractured hip, adduction of the limb, traction, and elevation are not appropriate procedures. Adduction means to move the limbs toward the medial plane, or axis, of the body, and traction involves the process of applying a pulling force in opposite directions using weights.

A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? Select all that apply. 1. Apply cool packs to her breasts to reduce the discomfort. 2. Take the analgesic medication prescribed to limit the discomfort. 3. Remove the infant from the breast for a few days to rest the nipples. 4. Never expose the nipples to air, only wear a tight fitting brassiere. 5. Assume a different position when breastfeeding to adjust the infant's sucking.

1. Apply cool packs to her breasts to reduce the discomfort, 2. Take the analgesic medication prescribed to limit the discomfort, 5. Assume a different position when breastfeeding to adjust the infant's sucking. Rationale: Applying cool packs to the breasts to reduce the discomfort may provide relief after a feeding. Analgesics may eventually be necessary. Altering the breastfeeding position may ensure that the entire nipple and as much of the areola as possible are in the infant's mouth. When the infant is latched on the nipple correctly and a finger is used to release suction at the end of a feeding, trauma to the nipple is reduced. Soreness is common; it usually occurs at the beginning of a feeding and is temporary, lasting till the nipples become accustomed to the infant's sucking. Nursing mothers should be encouraged to expose their nipples to air several times a day. Discontinuing feeding for several days will result in engorgement, which will increase the discomfort.

A client is admitted in preterm labor. After intravenous tocolytic medications are administered, contractions cease and she is discharged. She is to receive oral terbutaline (Brethine) 5 mg every 6 hours at home. When should the nurse advise the client to take the medication? 1. At mealtime/with food 2. At bedtime 3. Before breakfast 4. An hour after lunch

1. At mealtime/with food Rationale: One side effect of terbutaline (Brethine) is nausea and vomiting; to minimize this problem it should be ingested with food. Terbutaline should not be taken when the stomach is empty because it may cause gastrointestinal distress. One hour after a meal the digestive process has already begun and the stomach is emptying; terbutaline at this time may cause gastrointestinal distress.

A client with malabsorption syndrome is admitted to the hospital for medical intervention. A subclavian catheter is inserted and the client is started on total parenteral nutrition (TPN). What should the nurse teach the client to prevent the most common complication of TPN? 1. Avoid disturbing the dressing. 2. Keep the head as still as possible whenever moving. 3. Regulate the flow rate on the infusion pump as necessary. 4. Monitor daily weights at the same time while wearing the same clothing.

1. Avoid disturbing the dressing. Rationale: Disturbing the dressing may expose the area to pathogens. Infection is the most common complication; sterile technique at the catheter insertion site must be maintained. Keeping the head still is not necessary; the catheter is sutured in place, and reasonable movement is permitted. The client should be taught to leave the infusion pump set at the rate prescribed by the health care provider and to call the nurse if the alarm rings. Excessive weight gain or loss is not a complication of total parenteral nutrition.

About 6 hours after birth the nurse determines that a client's fundus is two fingerbreadths above the umbilicus and deviated to the right of the midline. What does the nurse suspect that the client has? 1. Bladder distention 2. Overstretched ligaments 3. Second-degree uterine atony 4. Retained placental fragments

1. Bladder distention Rationale: Bladder distention causes uterine displacement, which in turn interferes with uterine contraction and may lead to postpartum hemorrhage. The data do not indicate that the client had an unusually large baby or a multiple birth that could have resulted in overstretched ligaments. Uterine atony is not measured in degrees. Retained placental fragments often cause bright-red bleeding and a boggy uterus, but there are no data to support this conclusion.

A client has just been told that she has cervical erosion. The nurse would expect to help explain that early treatment of the erosion can help prevent: 1. Cancer of the cervix 2. Pelvic inflammatory disease 3. Unexpected vaginal bleeding Incorrect 4. Additional cervical erosions

1. Cancer of the cervix Rationale: Erosion of the cervix frequently occurs at the columnosquamous junction, the most common site for carcinoma of the cervix. Treatment of cervical erosions does not prevent pelvic inflammatory disease; early onset of sexual intercourse (before 16 years of age), multiple sexual partners, and history of human papillomavirus (HPV) infection are risk factors for cancer of the cervix rather than consequences of precervical cancer. Metrorrhagia, abnormal bleeding from the uterus, may be present as erosion develops into carcinoma; however, spotting may be the earliest sign and will be eliminated when the cancer is treated. The goal of treatment of the erosion is to prevent cancer.

After a vaginal hysterectomy and an anterior and posterior repair of the vaginal wall a client is returned to her room. What does the nurse include in the plan of care for this client? 1. Check vaginal packing. 2. Elevate lower extremities. 3. Observe dressing for bleeding. 4. Start sitz baths tomorrow morning.

1. Check vaginal packing. Rationale: Vaginal packing supports the repair and provides slight pressure to prevent bleeding; the packing should be checked for bleeding. Elevating the legs is unnecessary; leg exercises and a gradual increase in ambulation are encouraged to prevent pulmonary emboli. There is no dressing, only vaginal packing and a sanitary pad. Sitz baths are not instituted until the packing is removed; an ice pack, heat lamp, or both may be used to promote comfort.

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1. Clean the eyelid and eyelashes. 2. Place the dropper against the eyelid. 3. Apply clean gloves before beginning of procedure. 4. Instill the solution directly onto cornea. 5. Press on the nasolacrimal duct after instilling the solution.

1. Clean the eyelid and eyelashes., 3. Apply clean gloves before beginning of procedure., 5. Press on the nasolacrimal duct after instilling the solution. Rationale: Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.

What type of interview is most appropriate when a nurse admits a client to a clinic? 1. Directive 2. Exploratory 3. Problem solving 4. Information giving

1. Directive Rationale: The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

A peripheral nerve or dorsal column stimulator is implanted to allay a client's intractable pain. What discharge instructions should the nurse provide? 1. Disconnect the transmitter when taking a bath. 2. Analgesics will no longer be necessary. 3. The transmitter will be implanted and, therefore, not visible. 4. The transmitter will interfere with electronic devices.

1. Disconnect the transmitter when taking a bath Rationale: Clients may bathe when the transmitter is disconnected. Electrodes are attached to sensory nerves or over the dorsal column; a transmitter is worn externally and, by electric stimulation, may be used to interfere with the transmission of painful stimuli as needed. The client may need analgesics in conjunction with the transmitter. The transmitter should not interfere with other electronic devices.

Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. 1. Encouraging regular dental checkups 2. Facilitating smoking cessation programs 3. Administering influenza vaccines to older adults 4. Teaching the procedure for breast self-examination 5.Referring clients with a chronic illness to a support group

1. Encouraging regular dental checkups, 4. Teaching the procedure for breast self-examination Rationale: Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.) Correct 1. Gloves 2. Gown 3. Mask 4. Goggles 5. Shoe covers 6 Hair bonnet

1. Gloves, 2. Gown, 4. Googles Rationale: Standard personal protective equipment (PPE), which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. Shoe covers and hair bonnet are not required for the patient care situation described.

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity? 1. Nausea 2. Urticaria 3. Photophobia 4. Yellow vision

1. Nausea Rationale: Nausea and loss of appetite are the first indications of toxicity in approximately 50% of clients who take a cardiac glycoside, such as digoxin. Urticaria is a rare, not common, manifestation of digoxin toxicity. Photophobia is a later, not early, manifestation of digoxin toxicity. Yellow vision is a later, not early, manifestation of digoxin toxicity.

A nurse is teaching a female client about the side effects of estrogen in an oral contraceptive. Which common side effect identified by the client indicates to the nurse that the teaching was effective? 1. Nausea 2. Lethargy 3. Amenorrhea 4. Hypomenorrhea

1. Nausea Rationale: Nausea is related to the amount of hormone in the contraceptive. There may be an excess of estrogen; this symptom usually can be controlled by reducing the dose or by changing to another oral contraceptive. Lethargy can be related to excessive estrogen and progesterone, but they are not common side effects. Amenorrhea is associated with pregnancy; breakthrough bleeding is a more common response to estrogen. Hypomenorrhea is caused by estrogen deficiency.

A 4-day-old male infant with exstrophy of the bladder and ambiguous genitalia is in the neonatal intensive care unit. The everted bladder is inflamed, and there is continual leakage of urine onto the surrounding skin. What is the nurse's initial concern in trying to support the infant's mother? 1. Promoting her acceptance of her baby as he is 2. Preparing her for the surgery that her baby will require 3. Teaching her how to fulfill her baby's urinary needs 4. Instructing her in ways to meet her baby's emotional needs

1. Promoting her acceptance of her baby as he is Rationale: Before learning to care for her newborn emotionally and physically, the mother needs to begin to accept him as he is. It is too soon to prepare the mother for the impending surgery. The priority at this time is helping her accept her baby. Teaching the mother how to fulfill her baby's urinary needs is important, but teaching will be more effective if the mother first accepts the infant with the defect. The mother will be better able to meet her baby's emotional needs after she has accepted him.

A nurse is planning to teach the parents of a preterm infant about the infant's nutritional needs. Some nutrients are required in greater quantities in a preterm infant than a full-term one. Which nutrients should the nurse include in the plan? 1. Proteins 2. Carbohydrates 3. Vitamins A, D, E, and K 4.Calcium and phosphorus

1. Proteins Rationale: Proteins are needed for tissue building; therefore the preterm infant's need for protein is greater than the full-term infant's. Carbohydrates are not needed in greater quantities by the preterm infant than by the full-term infant. Vitamins A, D, E, and K are fat-soluble vitamins; all of these vitamins are needed, but the B vitamins, found in proteins, are most important for the preterm infant. Although minerals are needed for electrolyte balance, they are not the priority nutrient for a preterm newborn.

What does the nurse teach a client to do when performing breast self-examination? 1. Squeeze the nipples to examine for discharge. 2. Use the right hand to examine the right breast. 3. Place a pillow under the shoulder opposite the examined breast to raise it. 4. Compress breast tissue to the chest wall with the palm to palpate for lumps.

1. Squeeze the nipples to examine for discharge. Rationale: Serous or bloody discharge from the nipple is pathological and must be reported. The right hand should be used to examine the left breast because this allows the flattened fingers to palpate the entire breast including the tail (upper, outer quadrant toward the axilla) and axillary area. A small pillow or rolled towel should be placed under the scapula of the side being examined because it helps raise the chest wall and spread and flatten out breast tissue. The flat part of the fingers, not the palm or fingertips, should be used for palpation.

After 18 months of unsuccessful attempts at conception by a client, primary infertility related to anovulatory cycles is diagnosed. Clomiphene citrate (Clomid) is prescribed. The nurse concludes that the client understands the teaching about the correct time to take the clomiphene when the she states, "I'll start the pills on the: 1.Fifth day of my cycle" 2. Last day of my period" 3. Third day after my period" 4. 16th day of my cycle"

1.Fifth day of my cycle" Rationale: The objective is to stimulate ovulation near the 14th day of the menstrual cycle, and this is achieved by taking the medication on the fifth through the ninth days; there is an increase in two pituitary gonadotropins luteinizing hormone and follicle-stimulating hormone, with subsequent ovarian stimulation. On the third day after the cycle there are insufficient hormones for clomiphene to be effective. The 16th day of the cycle is also too late for clomiphene to be effective.

What should be included in nursing care immediately after a sexual assault? 1.Obtaining the assault history from the client 2.Informing the police before the client is examined 3.Having the client void a clean-catch urine specimen 4.Testing the client's urine for seminal alkaline phosphatase

1.Obtaining the assault history from the client Rationale: Obtaining the assault history from the client provides a basis for assessing trauma; in a client of childbearing age it also is necessary to assess the risk for pregnancy. Examination may precede reporting; the decision to report is mandated by law. Urination may wash away spermatic or bloody evidence. A test for seminal acid phosphate, not seminal alkaline phosphatase, is performed.

At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 PM tonight?" What is the nurse's best response? 1. "I will give one capsule tonight before bedtime." 2. "I will get a prescription so that the medicine can be taken." 3. "Does your health care provider know about your child's allergy?" 4. "Did you ask your health care provider if your child should have this tonight?"

2. "I will get a prescription so that the medicine can be taken." Rationale: Legally, a nurse cannot administer medications without a prescription from a legally licensed individual. The nurse cannot give the medication without a current health care provider's prescription; this is a dependent function of the nurse. The nurse should not ask if the health care provider is aware of the problem; it is the nurse's responsibility to document the client's health history. It is the nurse's responsibility to review the health care provider's prescriptions and question them when appropriate

At 36 weeks' gestation a client is scheduled for a contraction stress test (CST), and the nurse explains the procedure. Which statement indicates that the client understands the teaching? 1. "If this test causes my labor to begin early, it could affect the baby." 2. "If my baby's heart rate is OK, my labor won't be induced today." 3. "I hate having needles in my arm, but now I understand why it's necessary." 4. "I hope the baby doesn't get restless after the test; it can get uncomfortable."

2. "If my baby's heart rate is OK, my labor won't be induced today." Rationale: The client's remark that labor will not be induced today if the fetal heart rate is acceptable indicates that the mother understands that the well-being of the infant will be established by the testing. A CST should not precipitate labor. The CST does not always require an intravenous infusion; nipple stimulation may be used to initiate uterine activity. The fetus is not affected by external monitoring.

The nurse instructs a pregnant client in the sources of protein that can be used to meet the increased daily requirement during pregnancy. How many grams of protein should the client eat each day? 1. 65 g 2. 60 g 3. 55 g 4. 50 g

2. 60 g Rationale: The Food and Nutrition Board of the National Academy of Sciences recommends that a pregnant woman consume 60 g of protein daily to meet the needs of pregnancy. The recommended daily intake of protein for a breastfeeding (lactating) woman is 65 g. Fifty-five grams is less than the recommended daily intake of protein for a pregnant woman. Fifty grams is the recommended daily intake of protein for a healthy nonpregnant woman and does not meet the protein needs of a pregnant woman.

A nurse is caring for four new mothers on the postpartum unit. Which client is at the greatest risk for postpartum bleeding? 1. A primipara who has given birth to an 8-lb baby 2. A grand multipara who experienced a labor that lasted 1 hour 3. A multipara whose placental separation occurred 10 minutes after she gave birth 4. A primipara who received epidural anesthesia throughout the birthing experience

2. A grand multipara who experienced a labor that lasted 1 hour Rationale: Increased parity contributes to an increased incidence of uterine atony because the uterine muscle may not contract effectively, leading to postpartum hemorrhage; it is not uncommon for a grand multipara to have a labor that lasts 1 hour. A primipara should maintain a well-contracted uterus; with only one pregnancy, the uterus usually maintains its tone. Expulsion of the placenta 10 minutes after the birth of the fetus is expected and will not affect the tone of the uterus. Uterine atony is not a major problem associated with epidural anesthesia.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1. It stimulates plasma cells directly. 2. A high titer of antibodies is generated. 3. It provides immediate active immunity. 4. A long-lasting passive immunity is produced.

2. A high titer of antibodies is generated. Rationale: Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.

During a pelvic examination of a 24-year-old woman, the nurse suspects a vaginal infection because of the presence of a white curdlike vaginal discharge. What other assessment supports a fungal vaginal infection? 1. A foul odor 2. An itchy perineum 3. An ischemic cervix 4. A forgotten tampon

2. An itchy perineum Rationale: An itchy perineum usually occurs with candidiasis, a fungal infection; pruritus is the most common symptom. An odorous, frothy greenish discharge occurs with trichomoniasis, a protozoal infestation. Ischemia of the cervix is not associated with candidiasis; candidiasis causes vaginal and cervical inflammation. A forgotten tampon may cause bacterial, not fungal, vaginitis.

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. 1. Orientation 2. Capillary refill 3. Pupillary response 4. Respiratory rate 5. Pulse and skin temperature 6. Movement and sensation

2. Capillary refill, 5. Pulse and skin temperature, 6. Movement and sensation Rationale: A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? 1. Discharge planning is not covered by insurance. 2. Client cannot consent to his or her own surgery. 3. Postoperative complications occur that require additional treatment. 4. In case of the client's death, there will be directions about which client's belongings are to be given to family members.

2. Client cannot consent to his or her own surgery. Rationale: Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

A nurse manager whose leadership style is authoritarian can be described as: 1. Permissive 2. Controlling 3. Democratic 4. Contributive

2. Controlling Rationale: Leaders who exert strong control, are self-righteous, and expect others to follow them are known as authoritarian leaders. Leaders who are permissive and provide a minimum of leadership participation are known as laissez-faire leaders. Democratic leaders believe in collaboration and encourage others to contribute to the work effort. There is no leadership style called contributive. Democratic leaders believe in encouraging others to contribute to the work effort.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. 1. Difficulty in swallowing 2. Diminished sensation of pain 3. Heightened response to stimuli 4. Impaired hearing of high-frequency sounds 5. Increased ability to tolerate environmental heat

2. Diminished sensation of pain, 4. Impaired hearing of high-frequency sounds Rationale: Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A nurse evaluates that a client who is taking oral contraceptives understands the related dietary teaching when the client states, "While I'm taking birth control pills I should increase my intake of foods containing: 1. Calcium" 2. Folic acid" 3. Vitamin A" 4. Vitamin D"

2. Folic Acid Rationale: Oral contraceptives are thought to cause deficiencies of folic acid, vitamin C, vitamin B6 and vitamin B12. It is unnecessary to increase calcium intake when taking oral contraceptives. There is no clinical evidence to link oral contraceptives to a deficiency of vitamin A. There is no clinical evidence to link oral contraceptives to a deficiency of vitamin D.

The clinic nurse is providing home care instructions for a client with pelvic inflammatory disease. What resting position should be recommended by the nurse? 1. Sims 2. Fowler 3. Supine with knees flexed 4. Lithotomy with head elevated

2. Fowler Rationale: The Fowler position facilitates localization of the infection by pooling exudate in the lower pelvis. The Sims position and supine position with knees flexed do not use gravity to promote pooling of exudate in the lower pelvis. The lithotomy position with head elevated does not use gravity to promote pelvic drainage despite an elevated head.

A nurse is caring for a client who is receiving internal radiation for cancer of the cervix. For which adverse reactions to the radiotherapy should the client be monitored? Select all that apply. 1.Nausea 2.Hemorrhage 3.Restlessness 4.Vaginal discharge 5.Increased temperature

2. Hemorrhage, 5. Increases Temperature Rationale: Excessive sloughing of tissue may cause hemorrhage and is considered an adverse reaction. Infection, marked by an increase in temperature, may also develop from excessive sloughing of tissue. Nausea is an expected side effect of internal radiotherapy. Restlessness is not a sign of an adverse reaction; it is associated with a need to maintain a set position to prevent the applicator from being dislodged. Vaginal discharge is an expected side effect of internal radiotherapy.

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1. Exploring the client's emotional conflict 2. Identifying personal feelings toward this client 3. Planning to discuss this with the client's family 4. Developing a rapport with the client's health care provider

2. Identifying personal feelings toward this client Rationale: Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.

A client starting her second trimester asks a nurse in the prenatal clinic whether she can safely take an over-the-counter (OTC) medicine now that she is past the first 3 months of pregnancy. The nurse explains why she should consult with her health care provider before taking any oral medications. What physiologic alteration associated with pregnancy may change the client's response to medication? 1. Decreased glomerular filtration rate 2. Longer gastrointestinal emptying time 3. Increased secretion of hydrochloric acid 4. Development of fetal-placental circulation

2. Longer gastrointestinal emptying time Rationale: Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and the intestines laterally and posteriorly; absorption of some drugs, vitamins, and minerals may be increased because of their slow passage through the gastrointestinal tract. The glomerular filtration rate increases during pregnancy. The amount of gastric secretion is somewhat lower in the first and second trimesters; it increases in the third trimester. The development of fetal-placental circulation is unrelated to the absorption of drugs.

A nurse teaches a pregnant woman about the need to increase her intake of complete proteins. Which foods identified by the client indicate that the teaching is effective? Select all that apply. 1. Nuts 2. Milk 3. Eggs 4. Bread 5. Beans 6. Cheese

2. Milk, 3. Eggs, 6. Cheese Rationale: Milk contains animal proteins, which are complete proteins that contain all of the essential amino acids. Eggs contain animal proteins, which are complete proteins that contain all the essential amino acids. Cheese contains milk, which is a complete protein that contains of all the essential amino acids. Nuts are incomplete proteins. Bread is not a complete protein. Beans are not complete proteins unless eaten in a specific combination with soy products.

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. In doing so, the nurse is aware that in the problem-etiology-signs and symptoms (PES) format: 1. Signs and symptoms come last in the diagnostic process. 2. Nursing interventions are derived from the etiology statement. 3. The only allowable diagnoses are nursing diagnoses. 4. Nursing diagnoses deal only with actual or potential illness problems.

2. Nursing interventions are derived from the etiology statement. Rationale: The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the "S" comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses treat most frequently with other health care providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1. In the axillae 2. On the hands 3. On the right side 4. On the side that the client prefers

2. On the hands Rationale: Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side.

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? Select all that apply. 1. Heat 2. Pallor 3. Edema 4. Decreased flow rate 5.Increased blood pressure

2. Pallor, 3. Edema, 4. Decreased flow rate Rationale: The accumulation of fluid in the tissues between the surface of the skin and the blood vessels makes the skin appear pale. The accumulation of fluid in the interstitial compartment causes swelling. As the needle/catheter is dislodged from the vein, the drip rate of the IV slows or ceases. Heat is associated with phlebitis; the accumulation of room temperature IV fluid in the tissue makes the site feel cool. Increased blood pressure is a sign of circulatory overload; when an IV infusion has infiltrated, the intravascular fluid volume does not increase.

A nurse is implementing a teaching plan for a pregnant client who is noncompliant with maintaining bedrest. What is the most appropriate short-term goal? 1. Carrying the fetus to term 2. Remaining in bed as prescribed 3. Listing four reasons to stay in bed 4. Asking her husband to do the cooking

2. Remaining in bed as prescribed Rationale: Remaining in bed as prescribed is related to the immediate goal of maintaining bedrest. This is an objective measurement. Carrying the fetus to term is a long-term goal. Also, it is not related to the teaching associated with the treatment regimen. Clients are often able to explain why they should follow a proposed plan, even though they may not comply. Clients may not admit failure to adhere to the treatment regimen; demonstration of the desired behavior is an objective measurement. The goal focuses on what the client does in regard to maintaining bedrest. The client could be noncompliant with other activities.

A client asks a nurse about the most common problem associated with the use of an intrauterine device (IUD). What answer should the nurse provide? 1. Perforation of the uterus 2. Spontaneous device expulsion 3. Discomfort associated with coitus 4. Development of vaginal infections

2. Spontaneous device expulsion Rationale: The IUD may cause irritability of the myometrium, inducing contraction of the uterus and expulsion of the device. Perforation of the uterus is a rare, rather than a common, occurrence. Clients do not report discomfort during coitus when an IUD is in place. Increased incidence of vaginal infections is not reported with the use of an IUD.

A woman arrives at the prenatal clinic stating that her pregnancy test is positive. She asks the nurse for information about an abortion. After verifying that the woman is at 8 weeks' gestation, the nurse counsels her that having an abortion is controversial and that many women have long-lasting feelings of guilt after an abortion. What is the nurse's legal responsibility? 1. To share her own thoughts on abortion with the client 2. To provide the client with correct, unbiased information 3. To ask why the client wants information about abortion 4. To notify the health care provider because this is beyond the scope of nursing practice

2. To provide the client with correct, unbiased information Rationale: Nurses who counsel clients about abortion should know what services are available and the various methods that are used to induce abortion. Nurses who cannot control their negative feelings regarding abortion should not counsel women who are thinking of undergoing the procedure. Nursing practice necessitates knowledge of research results; statements must be based on fact, not personal feelings or beliefs. The nurse should give the client only the information requested, not state personal feelings. The nurse is responsible for giving information about abortion and need not defer to the health care provider.

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in: 1. Serum sodium 2. Urinary output 3. Hematocrit level 4. Serum potassium

2. Urinary output Rationale: As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

A male adolescent with cystic fibrosis (CF) whose parents are both carriers of the disease asks a nurse, "When I have children, could they have cystic fibrosis like me?" On what information about men with CF should the nurse base the response? 1. Generally they have a 50% chance of having children with the disease. 2. Usually they are unable to father children, although sexual function is not affected. 3. They have a greater chance of passing the disease to their children if their parents are carriers. 4. They do not pass this disease to their children because it is carried on the female sex chromosome.

2. Usually they are unable to father children, although sexual function is not affected. Rationale: Failure of the vas deferens, epididymis, and seminal vesicles to develop, or blockage of the vas deferens with viscous secretions, means that sperm production in CF is decreased or absent, and therefore most men with CF are sterile. CF is inherited as an autosomal recessive trait; it is not sex linked.

A nurse instructs a client who is taking oral contraceptives to increase her intake of dietary supplements. Which supplement should be increased? 1. Calcium 2. Vitamin C 3. Vitamin E 4. Potassium

2. Vitamin C Rationale: Oral contraceptives can affect the metabolism of certain vitamins, particularly vitamin C, and supplementation may be required. It is unnecessary to increase the intake of calcium when one is taking oral contraceptives. There is no clinical evidence linking oral contraceptives with a deficiency of vitamin E. There is no interrelationship between oral contraceptives and dietary intake of potassium.

During her first visit to the prenatal clinic a client is found to be obese. During the ensuing 5 months, the client has not been successful adhering to her nutritional plan. Which finding indicates to the nurse that the client has been successful during the sixth month? 1. Weight loss of 1 lb 2. Weight gain of 2 lb 3. No change in weight from last month 4. The client's statement that she lost weight last week

2. Weight gain of 2 lb 2. Weight gain of 2 lb Rationale: Although obese, the client must gain weight to meet the fetus's nutritional needs, and this weight gain is appropriate. Weight loss is contraindicated during pregnancy because it may interfere with fetal growth and development. Maintaining the same weight from last month to this month may indicate that the nutritional needs of the fetus are not being met. The client's statement that she lost weight last week does not constitute objective data.

Twelve hours after a spontaneous birth a client's temperature is 100.4° F (38° C). What does the nurse suspect as the cause of this increase in temperature? 1.Mastitis 2.Dehydration 3.Puerperal infection 4.Urinary tract infection

2.Dehydration Rationale: A client's temperature may increase to 100.4° F (38° C) during the first 24 postpartum hours as a result of dehydration and expenditure of energy during labor. Mastitis may develop after breastfeeding has been established and mature milk is present. An infection usually begins with a fever of 100.4° F (38° C) or more on 2 successive days, excluding the first 24 postpartum hours. Urinary tract infections usually become evident later in the postpartum period.

Before a male client signs an operative consent for an abdominoperineal resection, the nurse verifies that the client understands that surgery likely will result in which outcome? 1. Permanent ileostomy in the jejunum 2.Permanent colostomy and impotence 3.Temporary ileostomy and diminished libido 4.Temporary colostomy in the descending colon

2.Permanent colostomy and impotence Rationale: Large portions of bowel and rectum are removed; during the perineal portion of the surgery, nerves involved in penile erection often are damaged. An ileostomy will not be performed because the lesion is in the descending colon. A colostomy after an abdominoperineal resection is permanent because the rectum is removed; sexual functioning, not libido, may be affected. The descending colon is removed; the colostomy will be permanent.

A nurse is teaching a breastfeeding client about medications that are safe and unsafe for her to take. Which medication is contraindicated? 1. Heparin (Hep-Lock) 2.Propylthiouracil (PTU) 3. Gentamicin (Garamycin) 4. Diphenhydramine (Benadryl)

2.Propylthiouracil (PTU) Rationale: The concentration of propylthiouracil (PTU) excreted in breast milk is three to 12 times higher than its level in maternal serum; this may cause agranulocytosis or goiter in the infant. Heparin (Hep-Lock) is not excreted in breast milk. The amount of breast milk excretion of gentamicin (Garamycin) is unknown, but it can be given to infants directly without adverse effects. Diphenhydramine (Benadryl) is excreted in breast milk, but it does not adversely affect the infant when therapeutic doses are given to the mother.

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1. "I can ride my bike in about a week." 2. "I don't have to go to gym class for 3 months." 3. "I can't perform any weightlifting for at least 6 weeks." 4. "I can never participate in football again."

3. "I can't perform any weightlifting for at least 6 weeks." Rationale: Weightlifting puts a strain on the incision and should be avoided for at least 6 weeks. Activities such as bike riding and physical education classes and football are contraindicated for approximately 3 weeks after uncomplicated surgery for an inguinal hernia. Refraining from these activities for this period of time prevents stress on the incision and promotes healing. However, the client should not participate in any of these activities until cleared by the surgeon.

A client is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in preoperative teaching? 1. "Menstruation will stop after the surgery." 2. "You'll need to use birth control until your follow-up visit." 3. "You will be admitted as an outpatient for same-day surgery." 4. "You can have the operation reversed if you decide to have more children."

3. "You will be admitted as an outpatient for same-day surgery." Rationale: A laparoscopic tubal ligation takes about 20 minutes to perform. The client is admitted as an outpatient and goes home the same day after she recovers from the anesthesia. Menstruation will continue because there is no trauma to the ovaries or the endocrine glands involved with reproduction. Sterility is immediate; a waiting period is not required as it is with a vasectomy. Microsurgery to reverse the procedure is not guaranteed or easily accomplished.

A couple expresses a desire to use the rhythm method of birth control. The woman tells the nurse that she menstruates every 32 days. What should the nurse teach the couple about when the client's ovulation probably occurs? 1. On the 14th day of the cycle 2. 10 days after the first day of bleeding 3. 14 days before the start of the next menses 4. 2 to 3 days after the last day of menstrual bleeding

3. 14 days before the start of the next menses Rationale: In a regular cycle, ovulation occurs 14 days before the onset of the next menses. Ovulation occurs on the 14th day of the cycle in a woman who menstruates every 28 days. Ten days after the first day of bleeding is too early in the cycle for ovulation. Two or 3 days after the last day of menstrual bleeding is too early in the cycle for ovulation.

A 30-year-old client with a 35-day menstrual cycle is trying to become pregnant. The nurse counsels the client and her partner about the optimal timing of intercourse during the cycle. The nurse determines that the counseling has been effective when the couple state that they should have intercourse on the: 1. 12th day of the cycle 2. 14th day of the cycle 3. 21st day of the cycle 4. 25th day of the cycle

3. 21st day of the cycle Rationale: Ovulation usually occurs 14 days before menses; in a 35-day cycle, ovulation may occur as late as the 21st day. Day 12 day of the cycle is the proliferative phase of the cycle; ovulation has not yet occurred. If the woman had a 28-day cycle, ovulation is expected 14th day of the cycle. By the 25th day of the cycle, the ovum in this woman has passed out of the fallopian tube and can no longer be fertilized.

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1. Sprinkle the powder from the capsule into a cup of water. 2. Insert a rectal suppository containing 100 mg of phenytoin. 3. Administer 4 mL of phenytoin suspension containing 125 mg/5 mL. 4. Obtain a change in the administration route to allow an intramuscular (IM) injection.

3. Administer 4 mL of phenytoin suspension containing 125 mg/5 mL. Rationale: When an oral medication is available in a suspension form, the nurse can use it for clients who cannot swallow capsules. Use the "Desire over Have" formula to solve the problem. Desire 100 mg = x mL Have 125 mg 5 mL 125x = 500 X = 500 ÷ 125 X = 4 mL Because a palatable suspension is available, it is a better alternative than opening the capsule. The route of administration cannot be altered without the health care provider's approval. Intramuscular injections should be avoided because of risks for tissue injury and infection.

A client at 16 weeks' gestation is to have a sonogram followed by amniocentesis. When should the nurse direct the client to void? 1. Immediately before each procedure begins 2. An hour before the procedures are scheduled to begin 3. After the sonogram but before amniocentesis 4. Before the first sonogram tracing and after the last tracing

3. After the sonogram but before amniocentesis Rationale: A full bladder is required for effective visualization of uterine contents during the sonogram, but the bladder should be emptied before amniocentesis to help prevent accidental puncture of the bladder during the procedure. A full bladder is required to visualize the uterus with sonography when the uterus has not yet moved out of the pelvic cavity; a full bladder elevates the uterus.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1. Place the client in a left side-lying position. 2. Apply oxygen via non-rebreather mask. 3. Apply a petroleum gauze dressing over the site. 4. Prepare to reinsert a new chest tube.

3. Apply a petroleum gauze dressing over the site. Rationale: A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress.

What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging? 1. Achievement of a personal philosophy 2. Adaptation to the children leaving home 3. Attainment of a sense of worth as a person 4. Adjustment to life in an assisted-living facility

3. Attainment of a sense of worth as a person 3. Attainment of a sense of worth as a person Rationale: Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.

While caring for a family on a postpartum unit, a nurse must consider that parenting includes all of the tasks, responsibilities, and attitudes that make up child care and that either parent can exhibit these qualities. Which factor is the most important influence on parenting ability? 1. Inborn instincts 2. Marriage with flexible roles 3. Childhood roles and concepts 4. Education about growth and development

3. Childhood roles and concepts Rationale: Parenting is a learned, not an inborn, behavior based on past experiences and current motivation to learn. Specific marital roles do not influence parenting behaviors. Knowledge alone does not ensure the ability to parent.

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? 1. Thrombocytopenia 2. Oxygen deficiency 3. Clotting factor deficiency 4. Low hemoglobin

3. Clotting factor deficiency Rationale: FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets. It can be used to supplement red blood cells (RBCs) when other blood products are not available or to correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly with FFP, but it is not a definitive treatment.

A client is admitted to the emergency department with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Because it will produce passive immunity for several weeks with minimal danger of an allergic reaction, the nurse expects that what medication will be prescribed? 1. Tetanus toxoid (Td) 2. Equine tetanus antitoxin 3. Human tetanus antitoxin 4. Diphtheria, tetanus, pertussis (DTaP) vaccine

3. Human tetanus antitoxin Rationale: Human tetanus antitoxin (tetanus immune globulin [TIG]) provides antibodies against tetanus; it is used for the individual who may be infected and never has received tetanus toxoid or has not received it for more than 10 years. It confers passive immunity. Administration of the Td will produce active, not passive, immunity. Although equine tetanus antitoxin provides passive immunity, the risk for a hypersensitivity reaction is high and therefore TIG is preferred. DTaP vaccine produces active, not passive, immunity; in addition, DTaP usually is not given to adults.

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? 1. Dry mouth 2. Skin reactions 3. Mucosal edema 4. Bone marrow suppression

3. Mucosal edema Rationale: The mucosal lining of the oral cavity, oropharynx, and esophagus is sensitive to the effects of radiation therapy; the inflammatory response causes mucosal edema that may progress to an airway obstruction. A decrease in salivary secretions resulting in dry mouth may interfere with nutritional intake, but it is not life threatening. Erythema of the skin may cause dry or wet desquamation, but it is not life threatening. Radiation to the neck area should not produce as significant bone marrow suppression as radiation to the other sites.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1. faint, barely detectable. 2. slightly weak, palpable. 3. normal. 4. bounding.

3. Normal Rationale: The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1 + indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.

The nurse teaches a client who is scheduled for an elective cesarean birth several exercises that may be performed on the first postoperative day. The nurse concludes that further teaching is necessary when the client states that one of the exercises is: 1. Leg bends 2. Foot circles 3. Pelvic rocking 4. Shoulder circles

3. Pelvic rocking Rationale: Pelvic rocking on the first postoperative day could be very painful and might traumatize the wound site. Leg bends promote circulation in the lower extremities and help alleviate gas pains. Foot circles promote circulation in the lower extremities. Shoulder circles relieve neck stiffness and tension that may be present in the postpartum period.

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1. Respiratory rate. 2. Amount of oxygen in the blood. 3. Percentage of hemoglobin-carrying oxygen. 4. Amount of carbon dioxide in the blood.

3. Percentage of hemoglobin-carrying oxygen Rationale: The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate.

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? 1. Inspect and palpate in the epigastric region. 2. Auscultate and percuss in the inguinal areas. 3. Percuss and palpate in the hypogastric region. 4. Percuss and palpate bilaterally in the lumbar areas.

3. Percuss and palpate in the hypogastric region. Rationale: To detect a distended bladder, percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder would produce a dull sound and feel firm on palpation. Inspecting and palpating in the epigastric region, percussing and palpating in the hypogastric region or bilaterally in the lumbar areas are all inaccurate procedures to assess for a distended bladder.

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? 1. Crying 2. Splinting 3. Perspiring 4. Grimacing

3. Perspiring Rationale: Perspiration is an involuntary physiologic response. It is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain. Crying is an emotional response that may or may not be related to pain. Splinting is a voluntary action that may limit tension on the abdomen, thus reducing pain. Grimacing is a result of contraction of the facial muscles; it may or may not be a response to pain.

A nurse preceptor is evaluating a nurse who is preparing to administer digoxin (Lanoxin) intravenously (IV) to a client. The preceptor should stop the nurse from continuing with the procedure when the preceptor observes the nurse: 1. Checking the serum potassium level 2. Verifying the serum level of digoxin 3. Piggybacking the digoxin in an existing infusion 4. Administering the dose over a five-minute time period

3. Piggybacking the digoxin in an existing infusion Rationale: The nurse preceptor needs to stop the nurse because this action is unsafe. The manufacturer recommends that digoxin be infused alone because there may be an incompatibility with other medications. A low serum level of potassium and the administration of digoxin can cause toxicity. An elevated serum level of digoxin and the administration of another dose of digoxin can result in toxicity. Digoxin IV is given over a five-minute period through a Y-site connector.

Which action involving client needs may a nurse delegate to a nursing assistant? 1. Assessing a newly admitted client's contraction pattern 2. Discussing pain management options with a laboring client 3. Providing ice chips to a primigravida in early labor per order 4. Obtaining a sterile urine specimen for a suspected urinary tract infection

3. Providing ice chips to a primigravida in early labor per order Rationale: Providing ice chips to a primigravida in early labor per order does not require clinical knowledge or judgment for safe, effective care. Assessment, discussion of alternative actions, and the use of sterile technique during an invasive procedure all require clinical knowledge and judgment beyond the scope of practice of a nursing assistant.

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1.Evidence 2.Tort discovery 3. Proximate cause 4.Common cause

3. Proximate cause Rationale: Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? 1. Increased physical activity 2. Absence of further outbursts 3. Relaxation of tensed muscles 4.Denial of the need for further discussion

3. Relaxation of tensed muscles Rationale: Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that learning: 1. Reduces general anxiety 2. Is negatively affected by aging 3. Requires continued reinforcement 4. Necessitates readiness of the learner

3. Requires continued reinforcement Rationale: Neurologic aging causes forgetfulness and slower response time; repetition increases learning. The principle that learning reduces general anxiety is a general principle applicable to all learning. The older adult has no more difficulty learning than a younger person, although it may take longer. The principle that learning necessitates readiness of the learner is a general principle applicable to all learning.

A woman comes into the clinic and states that she is thinking about becoming pregnant. What can the woman do to improve the health of her baby before she becomes pregnant? 1. Go buy maternity clothes. 2. Start running 3 miles a day. 3. Start taking prenatal vitamins. 4. Buy a crib for the baby to sleep in.

3. Start taking prenatal vitamins. Rationale: Folic acid is important for the pregnant woman; a lack of folic acid can result in neural tube defects, including spina bifida. The time during fetal development when this occurs is very early in the pregnancy, when the woman may not even realize that she is pregnant. Taking prenatal vitamins with adequate folic acid can greatly reduce this birth defect. Although exercise is good for the pregnant woman and infant, it is not necessary to start running 3 miles a day, especially if this is something the client has never done before. Running may not be healthy for the soon-to-be mother and infant if it is a new activity; however, if this is what the woman normally does, she will be encouraged to continue. Buying maternity clothes or a crib is not necessary at this stage, and neither of these directly objects affects the health of the baby.

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? 1. Isoniazid (INH) 2. Rifampin (Rifadin) 3. Streptomycin 4. Ethambutol (Myambutol)

3. Streptomycin Rationale: Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment. Isoniazid does not affect the ear; however, blurred vision and optic neuritis, as well as peripheral neuropathy, may occur. Rifampin does not affect hearing; however, visual disturbances may occur. Ethambutol does not affect hearing; however, visual disturbances may occur.

To prevent footdrop in a client with a leg cast, the nurse should: 1. Encourage complete bed rest to promote healing of the foot. 2. Place the foot in traction. 3. Support the foot with 90 degrees of flexion. 4. Place an elastic stocking on the foot to provide support.

3. Support the foot with 90 degrees of flexion. Rationale: To prevent footdrop (plantar flexion of the foot due to weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

A nurse is evaluating a client's understanding regarding postoperative concerns after mastectomy. Which development near and around the incision noted by the client should be reported to her practitioner? 1. Persistent itching 2. Decreased sensation 3. Swelling with erythema 4. Irregular-appearing skin

3. Swelling with erythema Rationale: Swelling and erythema are signs of infection and should be reported to the health care provider. Itching is a sign of healing that is expected. Decreased sensation results from the severing of nerves and formation of scar tissue and is expected. There is little subcutaneous fat in the thoracic area, and the skin may be taut at the operative site, appearing irregular; this commonly occurs

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply. 1. Diplopia 2. Dysphagia 3. Tachypnea 4. Bradycardia 5. Hypotension

3. Tachypnea, 5. Hypotension Rationale: Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis.

A primipara about to be discharged with her newborn asks the nurse many questions regarding infant care. What phase of maternal adjustment does this behavior illustrate? 1. Let-down 2. Taking-in 3. Taking-hold 4. Early parenting

3. Taking-hold Rationale: The taking-hold phase, which begins about the second or third postpartum day, involves concern about being a "good" mother; the new mother is most receptive to teaching at this time. Let-down is not related to bonding. The let-down reflex refers to the flow of milk in response to suckling and is caused by the release of oxytocin from the posterior pituitary. The taking-in phase is the first period of adjustment to parenthood. It includes the first 2 postpartum days; the mother is passive and dependent and preoccupied with her own needs. The behavior described refers to the taking-hold phase of bonding. Early parenting involves many behaviors, of which taking-hold is only one.

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 1. Maligning a person's character while threatening to do bodily harm 2. A legal wrong committed by one person against property of another 3. The application of force to another person without lawful justification 4. Behaving in a way that a reasonable person with the same education would not

3. The application of force to another person without lawful justification Rationale: Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons instead of property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

The nurse reads the history of a neonate admitted to the nursery and discovers that the infant's mother was listed as gravida 1 para 1 before the baby was born. How should the nurse use these data to gather more information? 1. To determine whether there were previous fetal losses 2. To determine whether there are twins at home 3. To consider that someone recorded the gravida and para incorrectly 4. To consider that the current birth means that there were two pregnancies

3. To consider that someone recorded the gravida and para incorrectly Rationale: Gravida refers to pregnancies, including this one, and para refers to pregnancies terminated (by whatever means) after the age of viability. If this is the client's only pregnancy (gravida 1) she could not have had a previous pregnancy that ended after the age of fetal viability. Para will not exceed gravida. One pregnancy is gravida 1. A twin pregnancy is still one pregnancy terminated after the age of viability. Because the documentation of the client indicates that she is gravida 1, it cannot be assumed that it is the woman's second pregnancy. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of this text over an extended period of time ensures your understanding of the mechanics of the examination and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success.

A client is receiving therapy that includes a radioactive sealed implant. What nursing intervention should be implemented to protect against exposure to radiation? 1. Wearing a dosimeter film badge at all times 2. Limiting exposure to the client to one hour daily 3. Using long-handled forceps to retrieve a dislodged implant 4. Ensuring that visitors maintain a minimum distance of 3 feet from the client

3. Using long-handled forceps to retrieve a dislodged implant Rationale: Using long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room. Wearing a dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse's exposure to the radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 minutes daily.

A thin 24-year-old woman who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend? 1. Vitamin E and ginseng tea 2. Vitamin B and ginkgo biloba 3. Vitamin D and calcium citrate 4. Vitamin C and glucosamine/chondroitin

3. Vitamin D and calcium citrate Rationale: All women, except those who are pregnant or lactating, should ingest between 1000 and 1300 mg of calcium daily; if the client is unable to ingest enough calcium in food, supplements of calcium and vitamin D are recommended. Vitamin C and glucosamine/chondroitin maintain cartilage and connective tissue integrity but do not help prevent osteoporosis. The other supplements do not help prevent osteoporosis.

A nurse is counseling an obese postmenopausal client how to prevent bone loss. Which statements indicate understanding of the strategies to prevent bone loss? Select all that apply. 1. "I need to go on a strict diet." 2. "I'll take 400 mg of vitamin D every day." 3."I should take 1200 mg of calcium every day." 4."Swimming or bike riding five times a week is good for me." 5."Going to an aerobics class three times a week will help my bones."

3."I should take 1200 mg of calcium every day.", 5."Going to an aerobics class three times a week will help my bones." Rationale: The recommended daily intake of calcium for a postmenopausal woman is 1200 mg. Weight-bearing activities (e.g., walking, dancing, weightlifting, aerobic exercise) are best for building bone mass. Weight loss should be slow and reasonable; restricting calories promotes production of the hormone leptin, which stimulates bone loss. Eight hundred or more (up to 2,000), international units, not 400, of vitamin D are the recommended daily intake for a postmenopausal woman. Swimming and bike riding promote overall health and joint preservation but do not increase the strength or mass of bone.

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1.Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2.Develop a chart for the client, listing the times the medication should be taken. 3.Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4.Instruct the client and client's children to put medications in a weekly pill organizer.

3.Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Rationale: Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the outset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.

What nursing care is required for a client with a radium implant for cancer of the cervix? 1.Spending time with the client to alleviate her anxiety 2.Wearing a lead-lined apron for self-protection while in the room 3.Limiting the client's activity to avoid dislodging the radium insert 4.Using disposable sheets for protection from exposure to laundry personnel

3.Limiting the client's activity to avoid dislodging the radium insert Rationale: Activity must be limited so the implant will not be dislodged. While the client is receiving therapy, alpha, beta, and gamma rays will be emitted; therefore the nurse should employ the principles of time and distance when providing care. The extent of exposure to the client must be monitored and kept within safe limits, depending on the type and quantity of rays emitted. Wearing a lead-lined apron for self-protection while the nurse in the room is not necessary; adherence to principles of time and distance will protect the nurse from excessive exposure. Using disposable sheets for protection from exposure to laundry personnel is not necessary; however, all bed linens must be examined carefully for dislodged radium implants before the linens are sent to the laundry.

A client who is taking an oral contraceptive calls the nurse with concerns about side effects of the medication. Which adverse effect of this medication should alert the nurse to inform the client to immediately stop the contraceptive and contact the health care provider? Select all that apply. 1. Nausea 2. Weight loss 3.Visual disturbances 4.Persistent headaches 5.Decreased blood pressure

3.Visual disturbances, 4.Persistent headaches Rationale: Visual disturbances, such as partial or complete loss of vision or double vision, may indicate neuro-ocular lesions, which are associated with the use of oral contraceptives. Persistent headaches may indicate hypertension, which may occur with the use of contraceptives. Nausea is an expected side effect and does not require notification of the HCP. Weight gain, not weight loss, may occur because of edema. The client may experience hypertension, not hypotension.

A woman arrives at the women's health clinic complaining of frequency and burning pain when urinating. The diagnosis is a urinary tract infection. What is important for the nurse to encourage the client to do? 1. Void every 2 hours. 2. Record fluid intake and urinary output. 3. Pour warm water over the vulva after voiding. 4 Wash the hands thoroughly after urinating and defecating.

4 Wash the hands thoroughly after urinating and defecating. Rationale: Hand washing is medical aseptic technique and should limit the spread of microorganisms and help prevent future urinary tract infections if incorporated into the client's health practices. Voiding every 2 hours is unnecessary, but the client should be encouraged to void when the urge occurs. Intake and output need not be measured. Pouring warm water over the vulva after voiding is unnecessary for cystitis; it may be used as a part of perineal care for other problems.

A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond? 1. "Eat as you have been during your pregnancy." 2. "Drink a lot of milk—the added calcium will help you make milk." 3. "Your body produces the milk your baby needs as a result of the vigorous suckling." 4. "You'll need greater amounts of the same foods you've been eating and more fluids."

4. "You'll need greater amounts of the same foods you've been eating and more fluids." Rationale: Compared with the prenatal diet, the diet for lactation requires an increased intake of all food groups, vitamins, and minerals, plus increased fluid to replace that lost with milk secretion. Breastfeeding mothers need an additional 500 calories and 5 g of protein per day more than during pregnancy to maintain adequate milk production. The client needs additional calories, not just additional milk. Telling the client that her body produces the milk her baby needs as a result of the vigorous suckling does not address the mother's concern; optimal nutrition is necessary to produce an adequate milk supply.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? 1. Kidney dysfunction 2. Cardiovascular diseases 3. Eye problems, such as glaucoma 4. Accidents, including their prevention

4. Accidents, including their prevention Rationale: Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in the older adult.

A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1. Ask the client if he is okay. 2. Call security from the room. 3. Find out if there is anyone else in the room. 4. Ask security to make sure the room is safe.

4. Ask security to make sure the room is safe. Rationale: Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1. Skin turgor 2. Intake and output results 3. Client's report about fluid intake 4. Blood lab results

4. Blood lab results Rationale: Blood lab results provide objective data about fluid and electrolyte status as well as about hemoglobin and hematocrit. Intake and output results provide data only about fluid balance but doesn't present a comprehensive picture of the client's fluid and electrolyte status and therefore is not the best answer. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. The client's report about fluid intake is a subjective data in general and not reliable because this client has dementia and therefore has memory problems.

A nurse is caring for a client with tertiary syphilis. Which body system should the nurse monitor most closely? 1. Respiratory 2. Reproductive 3. Integumentary 4. Cardiovascular

4. Cardiovascular Rationale: Syphilis is primarily a vascular disease; aortitis, valvular insufficiency, and aortic aneurysms are the most prevalent problems in tertiary syphilis. Although lesions may occur around the mouth (chancre in primary syphilis, mucous patches in secondary syphilis), the structures of the respiratory tract are not the major structures involved in tertiary syphilis. Although lesions occur on the genitalia in primary and secondary syphilis, the reproductive system is not the major body system affected by tertiary syphilis. A gumma skin lesion is the least commonly occurring lesion associated with tertiary syphilis; skin lesions, such as macular and papular eruptions, most commonly occur in secondary syphilis.

A nurse preparing to apply restraints to a client should understand which of the following principles? 1. The law prohibits restraining clients until a written prescription is obtained. 2. A felony charge may be leveled against nurses who use restraints improperly. 3. Nurses are not obligated to report institutions that use restraints unlawfully. 4. Charges of assault and battery may be leveled against nurses who use restraints improperly.

4. Charges of assault and battery may be leveled against nurses who use restraints improperly. Rationale: Restraint of a client, whether physical or chemical, is considered a high-risk procedure requiring a valid health care provider's prescription and intensive monitoring for safety and meeting the client's needs. A nurse who does not follow correct procedures regarding restraints can legally be charged with assault and battery. Laws regarding restraint orders may differ from state to state and in different settings. A felony is a severe offense or crime such as murder, rape, or burglary and is commonly punished by imprisonment. Nurses have a professional obligation to report institutional misuse of restraints since this may constitute false imprisonment and abuse.

The unlicensed assistive personnel (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader? 1. Discuss the issue with a friend from another unit. 2. Remind the UAP of the expected start time. 3. Report the problem to the Human Resources department. 4. Document the information before discussing it with the UAP.

4. Document the information before discussing it with the UAP. Rationale: Documentation is the best initial response; documentation should include both the missed time and the effect on client care. Discussing the issue with a friend from another unit is not a professional or appropriate response to the problem. Reminding the UAP of the expected start time may be helpful but will not address the issue if the problem continues. Reporting the event to the Human Resources department may be a later response to the problem.

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? 1. Prolonged use can cause dark concentrated urine. 2. The medication is best absorbed when taken on an empty stomach. 3. Take the medication with aluminum hydroxide to minimize GI upset. 4. Drinking alcohol daily can cause drug-induced hepatitis.

4. Drinking alcohol daily can cause drug-induced hepatitis. Rationale: Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.

A nurse is teaching a group of women about the side effects of different types of contraceptives. What frequent side effect associated with the use of an intrauterine device (IUD) should the nurse discuss during the teaching session? 1. Tubal pregnancy 2. Rupture of the uterus 3. Expulsion of the device 4. Excessive menstrual flow

4. Excessive menstrual flow Rationale: After IUD insertion there may be excessive menstrual flow for several cycles. Because the IUD is a foreign body, there is an increase in the blood supply, a result of the inflammatory process. There is no documentation of a tubal pregnancy. Rupture of the uterus may occur on insertion but is uncommon. Expulsion of the device may occur, but it is not classified as a side effect.

What principle must a nurse consider when caring for a client with a closed wound drainage system? 1. Gravity causes fluids to flow down a pressure gradient. 2. Fluid flow rate is determined by the diameter of the lumen. 3. Siphoning causes fluids to flow from one level to a lower level. 4. Fluids flow from an area of higher pressure to one of lower pressure.

4. Fluids flow from an area of higher pressure to one of lower pressure. Rationale: A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device. Newton's law of gravity is not the physical principle underlying the functioning of a portable wound drainage system. Although fluid flow rate is determined by the diameter of the lumen and siphoning causes fluids to flow from one level to a lower level is true, they are not what cause the fluid to drain in a portable wound drainage system.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? 1. Side-lying with head elevated 45 degrees 2. Sims with head elevated 90 degrees 3. Semi-Fowler's with legs elevated 4. High Fowler's using the bedside table as an arm rest

4. High Fowler's using the bedside table as an arm rest Rationale: High Fowler's position elevates the clavicles and helps the lungs to expand, thus easing respirations. The other options do not promote more comfortable breathing.

A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication? 1. Take the medication with breakfast. 2. Have liver function tests every six months. 3. Wear sunscreen to prevent photosensitivity reactions. 4. Inform the health care provider if the client wishes to become pregnant.

4. Inform the health care provider if the client wishes to become pregnant. Rationale: Simvastatin is contraindicated in pregnancy because it is capable of causing fetal damage (teratogenic). It is a Pregnancy Category X teratogen. Simvastatin should be taken in the evening because most cholesterol is synthesized between 12 midnight and 3:00 AM. Liver function tests should be done at 6 to 12 weeks initially and only then every 6 months. Although wearing sunscreen should be taught, sensitivity reactions are a rare occurrence; it is not as important as an action in another option.

What nursing action best promotes parent-infant attachment behaviors? 1. Restricting visitors on the postpartum unit 2. Supporting rooming-in with parent-infant care 3. Encouraging the mother to choose breastfeeding 4. Keeping the new family together immediately after the birth

4. Keeping the new family together immediately after the birth Rationale: Research strongly supports the theory that there is a sensitive period during the first few hours of life that is important for the promotion of parent-infant attachment. Parent-infant bonding can take place with or without visitors. Encouraging rooming-in is helpful because it increases the amount of contact between the parents and the newborn, but it is not as significant as those critical first few hours after the birth. Contact with the newborn can be achieved with breastfeeding or formula feeding; it is the contact, not the method, that promotes bonding.

A pregnant couple is attending preparation-for-childbirth classes. Which exercise should the nurse teach the mother to increase the tone of the muscles of the pelvic floor? 1. Pelvic tilt 2. Half sit-ups 3. Pelvic rocking 4. Kegel exercises

4. Kegel exercises Rationale: Kegel exercises increase the tone of pelvic floor muscles and prepare the area for the second stage of labor. Pelvic tilting alleviates backache and strengthens the abdominal muscles, not the muscles of the pelvic floor. Half sit-ups strengthen the abdominal musculature, not the muscles of the pelvic floor. Pelvic rocking alleviates backache and strengthens abdominal muscles, not the muscles of the pelvic floor.

The nurse is preparing to assess the four abdominal quadrants of a client that complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant: 1. First 2. Second 3. Third 4. Last

4. Last Rationale: The nurse should systematically assess the abdomen concluding with the symptomatic area. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere with the assessment.

A pilot program is being developed to assist new mothers who are at risk for mother-infant relationship problems. Which mother's situation would make her a candidate for the program? 1. One whose pregnancy was not planned 2. One with negative feelings about the birth experience 3. One in whom the pregnancy elicited ambivalent feelings during the first trimester 4. One who had a preference for a child of one sex but gave birth to a baby of the other sex

4. One who had a preference for a child of one sex but gave birth to a baby of the other sex Rationale: The mother who had a child not of the sex she wanted is at risk for having difficulty with attachment because her baby did not meet her expectations. Unplanned pregnancies usually do not pose a risk for attachment problems because the decision was made to continue the pregnancy, giving the mother time to accept it. Reliving the birthing experience, whether it involves positive or negative feelings, occurs during the first few postpartum days during the taking-in phase. Unless there are other emotional problems, these feelings are resolved during this phase, and then the mother moves into the taking-hold phase, which starts the attachment process. Ambivalent feelings during the first trimester are common and usually resolve during the second trimester.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1. Oral psyllium (Metamucil) 2. Oral potassium supplement 3. Parenteral half normal saline 4. Parenteral albumin (Albuminar)

4. Parenteral albumin (Albuminar) Rationale: Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

What common concern of the mother after an unexpected cesarean birth should the nurse anticipate? 1. Postoperative pain 2. Prolonged period of hospitalization 3. Inability to assume the mothering role 4. Sense of failure in the birthing process

4. Sense of failure in the birthing process 4. Sense of failure in the birthing process Rationale: An unplanned cesarean birth may result in guilt, disappointment, anger, and a sense of failure as a woman. Postoperative pain is not usually a common concern. The hospital stay is not exceptionally prolonged; the client is usually discharged within two to four days. Mothers who have cesarean births are able to assume the mothering role to the same degree as women who have vaginal births.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1. Acknowledge the client's crying. 2. Encourage unrestricted family visits. 3. Explain details of the care being given. 4. Stay nearby without initiating conversation.

4. Stay nearby without initiating conversation. Rationale: The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy. Crying, part of depression, usually ceases when the individual reaches acceptance. During acceptance the client may decide not to have visitors, preferring time for reflection. Detached from the environment, the client may find that the details of various procedures lose significance.

A 60-year-old woman is admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. While taking the nursing history the nurse expects the client to state that one of the reasons she is having surgery is because she has been experiencing: 1.Hematuria 2. Dysmenorrhea 3. Pain on urination 4. Stress incontinence

4. Stress Incontinence Rationale: Increased intraabdominal pressure associated with lifting, coughing, or laughing, in conjunction with a relaxed pelvic musculature and a bladder displaced into the vagina, results in inability to suppress urination. Hematuria is usually associated with urinary tract infection, bladder tumor, or renal calculi, not with cystocele or rectocele. Dysmenorrhea is usually associated with pelvic inflammatory disease, endometriosis, or cervical stenosis, not with cystocele or rectocele; the client is probably postmenopausal. Pain on urination is usually associated with urinary infection, not with cystocele or rectocele.

A nurse is teaching a group of new mothers about breastfeeding. Which factor that influences the availability of milk in the lactating woman should the nurse include in the teaching? 1. Age of the woman at the time of delivery 2. Distribution of erectile tissue in the nipples 3. Amount of milk products consumed during pregnancy 4. Viewpoint of the woman's family toward breastfeeding

4. Viewpoint of the woman's family toward breastfeeding Rationale: If the woman perceives that significant others hold a negative view of breastfeeding, she may be tense and the let-down reflex may not occur; a positive attitude on the part of significant others toward breastfeeding promotes relaxation and the let-down reflex. The age of the woman at the time of the birth and distribution of erectile tissue in the nipples have no influence on lactation. Intake of milk or milk products during pregnancy has little influence on lactation.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1. Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3.Clean the insertion site daily using a solution of one part vinegar to two parts water. 4.Replace the drainage bag with a new bag once a week.

4.Replace the drainage bag with a new bag once a week. Rationale: Once a day, the client should wash the first inches of the catheter starting at the insertion site and moving outward. The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried. The drainage bag, not the insertion site, should be cleaned with the vinegar and water solution. It is recommended to change the bag at least once a week.

For clients to participate in goal setting, they should be: A: Alert and have some degree of independence. B: Ambulatory and mobile. C: Able to speak and write. D: Able to read and write.

A

Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A: Plan is developed for nursing care. B: Physical assessment begins C: List of priorities is determined. D: Review of the assessment is conducted with other team members.

A

The nursing care plan is: A: A written guideline for implementation and evaluation. B: A documentation of client care. C: A projection of potential alterations in client behaviors D: A tool to set goals and project outcomes.

A

To initiate an intervention the nurse must be competent in three areas, which include: A: Knowledge, function, and specific skills B: Experience, advanced education, and skills. C: Skills, finances, and leadership. D: Leadership, autonomy, and skills.

A

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, -4 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. Assess for a prolapsed cord B. Increase the intravenous fluids and start oxygen C. Notify the nurse-midwife D. Nothing, this is normal immediately after membranes rupture

A A A. With a -4 station, the fetus is at high risk for a prolapsed cord when the membranes rupture. B. If the pattern had been caused by uteroplacental insufficiency, then increasing the intravenous fluids and starting oxygen would be appropriate. C. It is important to notify the primary care giver with this pattern; however, it is not the first priority. The nurse should assess for a prolapsed cord and try to relieve the pressure. D. This is not a normal pattern after membranes rupture. It is nonreassuring

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 A. The tocotransducer monitors uterine activity and should be placed over the fundus where the most intensive uterine contractions occur. B. This is the placement for the internal scalp electrode. C. This is the placement for the intrauterine pressure catheter. D. The tocotransducer does not detect contractions if placed on the lower abdomen

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

A A. Variability cannot be determined by auscultation, because auscultation provides only an average fetal heart rate as it fluctuates. B. Tachycardia can be determined by electronic fetal monitoring and auscultation. C. Bradycardia can be determined by electronic fetal monitoring and auscultation. D. Fetal response to contractions is best determined by electronic fetal monitoring, but some responses can be determined through auscultation.

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 Normal scalp pH of a fetus is 7.25-7.35

When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A: Length of time the current treatment has been in place. B: The spouse's reaction to the client's dressing change. C: Client's concern about the current treatment. D: Physician's reluctance to change the current treatment plan.

A This gives the consulting nurse facts that will influence a new plan. (b, c, and d. These are all subjective and emotional issues/conclusions about the current treatment plan and may cause a bias in the decision of a new treatment plan by the nurse consultant.)

Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging

Answer- A Rationale - According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.

The guidelines for writing an appropriate nursing diagnosis include all of the following except: A. State the diagnosis in terms of a problem, not a need B. Use nursing terminology to describe the patient's response C. Use statements that assist in planning independent nursing interventions D. Use medical terminology to describe the probable cause of the patient's response

Answer- D Rationale- A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.

A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chest wall with a pillow

Answer: A Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important for client comfort, but come after an airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.

The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessing B. Diagnosing C. Planning D. Evaluating

Answer: B Rationale- The nurse identifies human responses to actual or potential health problems during the nursing diagnoses step of the nursing process. During the assessment step, the nurse collects data. During the planning step, the nurse develops strategies to resolve or decrease the patient's problem. During evaluation, the nurse determines the effectiveness of the plan of care.

A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality B. Provide time for privacy C. Suggest referral to a sex counselor or other appropriate professional D. Provide support for the spouse

Answer: C Rationale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally does not provide sex counseling. While providing time for privacy and providing support for the spouse is important, it is not as important as referring the client to a sex counselor/appropriate professional.

While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be: A. Potential for impaired skin integrity R/T altered gland function B. Potential for impaired skin integrity R/T dehydration C. Impaired skin integrity R/T dehydration D. Impaired skin integrity R/T altered circulation

Answer: C Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst.

Independent nursing interventions commonly used for immobilized patients include all of the following except: A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated B. Deep-breathing and coughing exercises with change of position every 2 hours C. Diaphragmatic and abdominal breathing exercises D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy

Answer: D Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order.

The most important nursing intervention to correct skin dryness is: A. avoid bathing until the condition is remedied and notify physician B. ask physician to refer the patient to a dermatologist C. Consult the dietitian about increasing fat intake, and take necessary measures to prevent infection D. encourage the patient to increase fluid intake, use nonirritating soap, and apply lotion to involved areas

Answer: D Rationale- Preventative measures, such as these, will prevent the skin from cracking, which would make the client more prone to infection. The other 3 answers are options, however NOT the best choice for this particular situation.

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain R/T surgery B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired physical mobility R/T surgery D. Risk for aspiration R/T anesthesia

Answer: D Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this.

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient? A. Reassess the patient B. Examine the related to factors C. Analyze the secondary to factors D. Review the defining characteristics

Answer: D Rationale- The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.

The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: A. Diagnose if the patient is at risk for falls. B. Ensure that the patient's skin is intact C. Establish a therapeutic relationship D. Identify important data

Answer: D Rationale- This is the primary purpose of a nursing admission assessment.

A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place? A. Assessment B. Planning C. Implementation D. Evaluation

Answer: D Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established have been achieved, and evaluates the success of the plan. Answer A involves data collection. Answer B involves setting priorities, and Answer C is the actual intervention.

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time? A. Impaired gas exchange related to increased blood flow B. Fluid volume excess related to peripheral vascular disease C. Risk for injury related to edema D. Altered peripheral tissue perfusion related to venous congestion

Answer: D Rationale: This answer takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion

Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime B. Ask the client each morning to describe the quantity of sleep the night before C. Teach the client relaxation techniques, such as guided imagery and progressive muscle relaxation D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks

Answer: D Rationale: You should begin with the simplest interventions. Answer A is incorrect because medications should be avoided whenever possible. Answer B would be a thorough sleep assessment, and should be done only after common sense interventions fail. Answer C would be appropriate only after common sense interventions fail.

The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A: A client who is ambulatory. B: A client, who has a fever, is diaphoretic and restless. C: A client scheduled for OT at 1300. D: A client who just had an appendectomy and has just received pain medication.

B

The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? A: A client's family attending a diabetic teaching session. B: Cancelling physical therapy sessions on the weekend. C: Normal VS and absence of wound infection in a post-op client. D: A client demonstrating accurate medication administration following teaching.

B

When establishing realistic goals, the nurse: A: Bases the goals on the nurse's personal knowledge. B: Knows the resources of the health care facility, family, and the client. C: Must have a client who is physically and emotionally stable. D: Must have the client's cooperation.

B

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 uteroplacental 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 A. An early deceleration would end when the contraction phase is over. This pattern continues beyond the end of the contraction. B. This is a description of a late deceleration. Oxygen should be given via snug facemask. The nurse should position the woman on her side to increase placental blood flow. C. Variable decelerations drop suddenly and return to baseline suddenly. They are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. D. This pattern is nonreassuring. The intravenous fluid should be increased to increase the woman's blood volume.

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

B A. Oxytocin use does not have hypotension as a common side effect. B. The uterus may contract more firmly, and the resting tone may be increased with oxytocin use. This reduces entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. C. Oxytocin may increase the maternal fluid volume. However, this is not the reason for fetal monitoring. D. Oxytocin does not stimulate the fetal chemoreceptors

Which of these conditions may cause the fetal heart rate to be lower during labor? (Choose 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, C, D Stimulation of the baroreceptors and the parasympathetic nervous system will lower the heart rate. Initial decreased oxygen content and increased carbon dioxide content will trigger an increase in the heart rate. However, if this condition continues, the heart rate will lower.

Planning is a category of nursing behaviors in which: A: The nurse determines the health care needed for the client. B: The Physician determines the plan of care for the client. C: Client-centered goals and expected outcomes are established. D: The client determines the care needed.

C

The nurse writes an expected outcome statement in measurable terms. An example is: A: Client will have less pain. B: Client will be pain free. C :Client will report pain acuity less than 4 on a scale of 0-10. D: Client will take pain medication every 4 hours around the clock.

C

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 A. A normal rate averages between 110 and 160 bpm. B. Bradycardia is a rate less than 110 bpm for at least 10 minutes. C. Tachycardia is a heart rate greater than 160 bpm, persisting for at least 10 minutes. D. Acceleration is an increase in the heart rate that lasts for a short period of time before returning to baseline

Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A: Physician B: Non Emergent, non-life threatening needs C: Future well-being. D: Urgency of problems

D

She is the first one to coin the term "NURSING PROCESS" She introduced 3 steps of nursing process which are Observation, Ministration and Validation. A: Nightingale B: Johnson C: Rogers D: Hall

D

Well formulated, client-centered goals should: A: Meet immediate client needs. B: Include preventative health care. C: Include rehabilitation needs. D: All of the above.

D

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

External electrodes To use internal electrodes, the woman mush be 2 cm dilated and have ruptured membranes. Her membranes are intact. Therefore, external electrode monitoring is the choice of her.

Independent nursing interventions commonly used for patients with pressure ulcers include: A. changing the patient's position regularly to minimize pressure B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site C. Debriding the ulcer to remove necrotic tissue, which can impede healing D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated

Independent nursing interventions commonly used for patients with pressure ulcers include: A. changing the patient's position regularly to minimize pressure B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site C. Debriding the ulcer to remove necrotic tissue, which can impede healing D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated

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 ______________.

Late deceleration A late deceleration shows a pattern of fetal heart decelerations that begin late in the contraction phase and goes back to baseline after the contraction has ended.