exam 5 questions and others

A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to which major deficiency? 1 Ferrous sulfate 2 Protein 3 Ascorbic acid 4 Linoleic acid

2 Protein deficiency causes a low serum albumin level, which permits fluid shifts from the intravascular to the interstitial compartment, resulting in edema. Decreased protein also causes anemia; protein intake must be increased. Although a deficiency of ferrous sulfate will result in anemia, it will not cause the other adaptations. Ascorbic acid is unrelated to these adaptations. Linoleic acid is unrelated to these adaptations.

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be correct to include in the teaching plan? Select all that apply. One, some, or all responses may be correct. 1 Whole grains 2 Cooked fruits and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs

1,2,3,5 With diverticular disease, the client should avoid foods that may obstruct the diverticula; therefore the fiber should be digestible, such as whole grains and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. Although it has been believed in the past that avoiding nuts and seeds would prevent diverticulitis, there is no evidence to support this claim and nuts and seeds can be consumed as long as they are thoroughly chewed. For clients with diverticular disease, the client should decrease intake of fats and red meats.

Which scenarios mentioned by the student nurse relate to the health care ethic of fidelity? Select all that apply. One, some, or all responses may be correct. 1 Monitoring a client after providing nonpharmacological measures to relieve anxiety due to hospitalization 2 Noting that the pain relief measures provided to that client have been ineffective, the nurse formulates a different plan of care 3 Ensuring that the client understands the risks and benefits of an experimental treatment before signing the appropriate consent form 4 Carefully evaluating the advantages and disadvantages of the client's plan of care to ensure that the risks do not outweigh the benefits 5 Caring for a client who refuses to be touched by people of certain skin color, the nurse continues to provide care because other colleagues refuse to attend to the client.

1,2,5 According to the health care ethic of fidelity, the nurse is required to keep all health care promises made to the client. If the nurse assesses the client to relieve anxiety regarding hospitalization, it is essential to monitor for effectiveness of the treatment plan after initiating interventions. If the nurse assesses the client for pain and notes that relief measures have been ineffective, the nurse would formulate alternate treatment plans. Fidelity also involves an unwillingness to abandon clients when care becomes controversial or complex. In the given situation, the client has a controversial belief system about skin color. However, the nurse continues to provide care even when other colleagues refuse to do so. The health care ethic of autonomy deals with the inclusion of clients in important decisions regarding care plans. The client is required to understand the risks and benefits of experimental procedures before signing the consent form. This ensures the client's independence. The health care ethic of nonmaleficence focuses on doing no harm. In the given situation, the nurse ensures that the risks of the treatment plan do not outweigh the benefits, to minimize harm to the client.

Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation? Select all that apply. One, some, or all responses may be correct. 1 Using hydrogen peroxide 2 Inserting a catheter without suction 3 Placing the client in the recumbent position 4 Rinsing the inner cannula with normal saline 5 Changing both tracheostomy ties at same time

4 When removing the inner cannula, it must be rinsed with normal saline; hydrogen peroxide is only used if an infection is present. A catheter is inserted into the cannula when suctioning. The client would be placed in the semi-Fowler position. The nurse would change one tracheostomy tie at a time to ensure that the cannula stays in place.

Maslow's Hierarchy of Needs

(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization

Which variables are scored on a biophysical profile? Select all that apply. One, some, or all responses may be correct .1Fetal tone 2Fetal position 3Fetal movement 4Amniotic fluid index 5Fetal breathing movements 6Contraction stress test results

1 3 4 5

Which term would the nurse use to describe the first fetal movements that a pregnant client feels? 1Lightening 2Quickening 3Engagement 4Ballottement

2 Lightening is the descent of the fetus into the birth canal toward the end of pregnancy. Engagement occurs when the presenting part is at the level of the ischial spines. Ballottement refers to the technique that causes the fetus to rebound in the amniotic fluid after pressure has been exerted against the fetus.

imbalance of what electrolytes can be associated with leg cramps in pregnancy

calcium, magnesium, phosphorus

the uterus should no longer be palpable __ weeks after delivery and should return to normal size __ weeks after delivery.

2, 6

what decreases gastric secretion by inhibiting histamine at H2 receptors. Increasing gastric motility, neutralizing gastric acidity, and facilitating histamine release are not actions of famotidine?

famotidine

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. Which signs would the nurse expect when assessing the client? Select all that apply. One, some, or all responses may be correct. 1 Fever 2 Tachypnea 3 Hypertension 4 Abdominal rigidity 5 Increased bowel sounds

1,2,4 The metabolic rate will be increased, and the temperature-regulating center in the hypothalamus resets to a higher-than-usual body temperature because of the influence of pyrogenic substances related to the peritonitis. Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. With increased intra-abdominal pressure, the abdominal wall will become rigid and tender. Hypovolemia and hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intra-abdominal pressure.

A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and having experienced 10 liquid bowel movements in the past 24 hours. The nurse suspects that the client is dehydrated based on which assessment findings? Select all that apply. One, some, or all responses may be correct. 1 Moist skin 2 Sunken eyes 3 Decreased apical pulse 4 Dry mucous membranes 5 Increased blood pressure

2,4 Sunken eyes and loss of skin turgor occur because of decreased intracellular and interstitial fluid associated with dehydration. Dry mucous membranes occur because of decreased intracellular and interstitial fluid associated with dehydration. The skin will be dry, not moist, with dehydration. The first sign of dehydration usually is tachycardia. The blood pressure will decrease, not increase, because of hypovolemia.

The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? 1 The partial pressure of oxygen (PO2) value is 80 mm Hg. 2 The partial pressure of carbon dioxide (PCO2) value is 60 mm Hg. 3 The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L). 4 Serum potassium value is 4 mEq/L (4 mmol/L).

3 The HCO3 value is elevated. The urinary system compensates by retaining hydrogen (H+) ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO3 value is 21 to 28 mEq/L (21-28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis the PCO2 level may be increased, it is the increased HCO3 level that indicates compensation. A potassium (K+) level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5-5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition is indicated with this result? 1Cystic fibrosis 2Phenylketonuria 3Down syndrome 4Neural tube defect

4 neural tube defectIncreased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.

Which explanation would the registered nurse provide to a nursing student regarding the characteristics of a primary nursing care delivery model? 1 "There is lateral communication from nurse to nurse and caregiver to caregiver." 2 "Team members provide direct client care under the supervision of the registered nurse (RN)." 3 "The team leader develops client care plans, coordinates care among team members, and provides care requiring complex nursing skills." 4 "There is hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members."

1 The primary nursing care delivery model involves lateral communication from nurse to nurse and caregiver to caregiver. According to the team nursing care delivery model, team members provide direct client care under supervision of the registered nurse (RN). The team leader develops client care plans, coordinates care among team members, and provides care requiring complex nursing skills. Hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members is a characteristic of the team nursing care delivery model.

Which situations represent the id component of human personality as mentioned by Freud? Select all that apply. One, some, or all responses may be correct. 1 A client experiencing pain takes pain medication prescribed for a family member. 2 A client feels nauseous; therefore he or she leaves work midway to go to a health care facility. 3 A client wishes to go home and slips out of the health care facility quietly without anyone noticing. 4 A client feeling hungry notices a food tray at the next bed but does not grab the food because a nurse is watching. 5 A client feeling thirsty waits for the nurse to bring him or her water instead of taking it from the next client because he or she knows this is wrong.

1,2,3 According to Freud, the components of human personality develop in stages and affect behavior. The three components are the id, the ego, and the superego. The id represents basic human instincts and impulses that are driven by the goal of achieving pleasure. In the given situation, the client feels the need to reduce pain and takes a medication prescribed for a different person. This is an example of id. A client who leaves work midway to go to the health care facility because of nausea is also exhibiting id behavior. Another example of id behavior is exhibited by a client who wishes to go home and slips out of the health care facility instead of following proper protocol. A client who is hungry and is tempted by the food tray beside the next bed but controls himself or herself because the nurse is watching exhibits ego behavior. A client who feels thirsty but understands that it is wrong to take water given to another client and instead waits for the nurse to bring water exhibits superego behavior.

Which functions of leukocytes are involved in the inflammation process? Select all that apply. One, some, or all responses may be correct. 1 Destruction of bacteria and cellular debris 2 Selective attack and destruction of non-self cells 3 Release of vasoactive amines during allergic reactions 4 Secretion of immunoglobulins in response to a specific antigen 5 Enhancement of immune activity through secretion of various factors, cytokines, and lymphokines

1,3 Leukocytes such as monocytes and eosinophils are involved in inflammation. Their functions include the destruction of bacteria and cellular debris and the release of vasoactive amines to limit allergic reactions. Helper/inducer T-cells and cytotoxic cells selectively attack and destroy non-self cells and secrete immunoglobulins in response to the presence of a specific antigen. B-lymphocytes, or plasma cells, secrete immunoglobulins in response to the presence of a specific antigen. Helper/inducer T-cells are involved in cell-mediated immunity, enhancing immune activity through the secretion of various factors, cytokines, and lymphokines.

How is the term beneficence in health ethics different from nonmaleficence? 1 Beneficence refers to fairness, whereas nonmaleficence refers to the agreement to keep promises. 2 Beneficence involves taking positive actions to help others whereas nonmaleficence is the avoidance of harm or hurt. 3 Beneficence stands for all health care professionals, whereas nonmaleficence stands for nursing professionals. 4 Beneficence refers to the support of a particular cause, whereas nonmaleficence refers to a willingness to respect one's professional obligations.

2 Beneficence is the act of taking positive actions to help others; nonmaleficence is the avoidance of harm or hurt. Justice refers to fairness; fidelity refers to the agreement to keep promises. Both beneficence and nonmaleficence stand for all health care professionals. Advocacy refers to the support of a particular cause; responsibility refers to a willingness to respect one's professional obligations.

Which instruction would the nurse provide to the client in early pregnancy scheduled for her first obstetric ultrasound? 1Postpone breakfast until after the test .2Drink water until bladder is full. 3Empty the bladder immediately before the test. 4Insert a suppository after arising on the day of the test

2 drink water until bladder is fullA full bladder raises the uterus above the pelvis, providing better visualization of its contents. This preparation is helpful for the transabdominal portion of the ultrasound. The client may then be allowed to void before the transvaginal portion of the ultrasound. It is not necessary to arrive for the test with an empty stomach. The bladder should not be emptied until after the test. It is not necessary to evacuate the bowels before the test.

A client at 42 weeks' gestation is admitted for a nonstress test. The nurse concludes that this test is being done because of which possible complication related to a prolonged pregnancy? 1Polyhydramnios 2Placental insufficiency 3Postpartum infection 4Subclinical gestational diabetes

2 placental insufficiencyPlacental function peaks at 37 weeks and declines slowly thereafter; therefore, continuation of the pregnancy past term (42 weeks) places the fetus at risk because of placental insufficiency. Oligohydramnios (decreased amniotic fluid volume), not polyhydramnios (increased amniotic fluid volume), may occur in postterm gestations. A prolonged pregnancy does not present a risk for a postpartum infection. A prolonged pregnancy is unrelated to gestational diabetes.

A client with severe preeclampsia has audible crackles in the lower left lobe, slight blurring of vision in the right eye, generalized facial edema, and epigastric discomfort. Which of these clinical manifestations is most indicative of an impending seizure? 1Audible crackles 2Blurring of vision 3Epigastric discomfort 4Generalized facial edema

3 Epigastric discomfort suggests liver edema; it is an ominous symptom that indicates an impending seizure. Audible crackles indicate pulmonary edema, but although they are a sign of severe preeclampsia they are not as definitive as epigastric pain. Blurred vision is a sign of retinal edema; although it is a sign of severe preeclampsia, it is not as definitive as epigastric pain. Although generalized facial edema is an indication of severe preeclampsia, it is not as definitive as epigastric pain.

Which recommendation would the nurse provide to a client with gastroesophageal reflux disease (GERD) who asks how to reduce heartburn and pain without taking medication? Select all that apply. One, some, or all responses may be correct. 1 Chew hard mint candies. 2 Eat a small bedtime snack. 3 Elevate the head of the bed 5 inches. 4 Avoid white wine consumption. 5 Consume three large meals per day.

3 The nurse would instruct the client to elevate the head of the bed 4 to 6 inches as this prevents reflux of gastric contents into the esophagus. Mints, especially peppermint, weaken lower esophageal sphincter (LES) pressure and allow gastric contents to reflux. The client should refrain from eating 3 hours before bed as this also affects the LES pressure. Red wine weakens the LES pressure. The client would be instructed to eat small, frequent meals to prevent gastric distention.

A client in labor is receiving an oxytocin infusion. Which intervention is a priority for the nurse when repetitive late decelerations of the fetal heart rate are observed? 1Administer oxygen. 2Place the client on the left side. 3Discontinue the oxytocin infusion. 4Check the client's blood pressure

3 Treat the immediate potential cause of the decelerations by discontinuing the oxytocin infusion. The infusion should be stopped because it is the likely source of fetal compromise. Additional interventions including administering oxygen, placing client on the left side, and monitoring vital signs should be initiated to support both the mother and the unborn child. These interventions are supportive therapy—not treatment of the cause.

A client admitted with a history of emphysema and a diagnosis of acute respiratory failure with respiratory acidosis has oxygen at 3 L/min nasal cannula. Four hours after admission, the client exhibits increased restlessness and confusion followed by a decreased respiratory rate and lethargy. Which intervention would the nurse implement at this time? 1 Question the client about the confusion. 2 Change the method of oxygen delivery. 3 Percuss and vibrate the client's chest wall. 4 Discontinue or decrease the oxygen flow rate.

4 With emphysema, the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe but rather to lowered oxygen levels; therefore the nurse needs to lower the delivered oxygen to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe. However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicated a preserved hypercarbic drive. Clinical application of this theory requires more research. A confused client cannot answer questions about the confusion. There are no indications of increased respiratory secretions.

Which client is at an increased risk for hospital-acquired pneumonia? Select all that apply. One, some, or all responses may be correct. 1 Client who was admitted yesterday with hypoxia and fever 2 Client who has been on mechanical ventilation for 5 days 3 Client who reports being on an airplane with other sick individuals 4 Client who presents to the emergency department with cough and crackles 5 Client who was admitted to the hospital 5 days ago for abdominal pain

5 Hospital-acquired pneumonia occurs in nonintubated clients and begins 48 hours after admission. A client admitted 5 days ago with abdominal pain would meet the criteria and is at increased risk for hospital-acquired pneumonia. A client admitted the previous day has not been in the hospital at least 48 hours. A client on mechanical ventilation is intubated and does not meet the criteria for hospital-acquired pneumonia. A client who has been on an airplane with other ill individuals would be at risk for community-acquired pneumonia. A client in the emergency department has not been admitted to the hospital.

Dumping syndrome

Rapid emptying of gastric contents into small intestines. Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia, vertigo, sweating

REEDA assessment

Redness Edema Ecchymosis Discharge, Drainage Approximation

Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct. 1 Tachycardia 2 Hypotension 3 Rigid abdomen 4 Nausea and vomiting 5 Back and shoulder pain

all Perforation of an ulcer can cause tachycardia and hypotension (both caused by fluid volume shifts from the vascular compartment to the abdominal cavity). A client with a perforated ulcer would have a hard, rigid abdomen (caused by tensed muscles) and nausea and vomiting. Back and shoulder pain can occur as a result of irritation of the phrenic nerve.

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor? a. Large bowel obstruction b. Dyspepsia c. Upper gastrointestinal (GI) bleeding d. Gastric cancer

c Peptic ulcer disease (PUD) can cause gastric mucosal damage or perforation, which causes upper GI bleeding. Dyspepsia is a symptom of PUD, gastritis, and gastric cancer. PUD affects the stomach and/or duodenum, not the colon.

During a nonstress test, the baseline fetal heart rate of 130 to 140 beats per minute rises to 160 twice and 157 once during a 20-minute period. Each of these episodes lasts 20 seconds. Which action would the nurse take?1Discontinue the test because the pattern is within the normal range. 2Encourage the client to drink more fluids to decrease fetal heart rate 3Notify the primary health care provider and prepare for an emergency birth. 4Record this nonreassuring pattern and continue the test for further evaluation.

1 A reactive nonstress test is an expected finding because there are 2 or more increases in FHR greater than 15 beats/min associated with fetal movement; it suggests fetal well-being. There are no uterine contractions during a nonstress test. Maternal movement has no bearing on nonstress test readings; fetal movements and FHR are monitored.

A client with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face is diagnosed with severe preeclampsia. Which other clinical findings support this diagnosis? Select all that apply. One, some, or all responses may be correct. 1Headache 2Constipation 3Abdominal pain 4Vaginal bleeding 5Visual disturbances

1 3 5 A blood pressure higher than 140 mm Hg systolic and 90 mm Hg diastolic along with proteinuria is diagnostic of preeclampsia; assessments should be performed twice, 4 to 6 hours apart. Hypertension alone does not support a diagnosis of preeclampsia. Hypertension accompanied by a headache is not necessarily indicative of preeclampsia. Blood pressure above the baseline and fluctuating with each reading may occur at any time, not specifically in a client with untreated preeclampsia.

Which situations qualify under the fourth level of Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct. 1 A client laments that he or she is the ugliest person in the whole world. 2 A client informs the nurse that he or she has been living alone for the past decade. 3 A client tells the nurse that he or she feels out of breath, even when walking slowly. 4 A client tells the nurse that he or she is the only member in the family who does not work. 5 A client feels that he or she has not been able to live up to his or her partner's expectations.

1,4,5

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and intravenous (IV) fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? 1 Reduce gastric acidity 2 Reduce colonic irritation 3 Reduce intestinal absorption 4 Reduce bowel infection rate

2 A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is followed to allow the bowel to rest, not to reduce infection rates.

The nurse provides discharge teaching for a client after a laparoscopic cholecystectomy. Which statement indicates to the nurse that the client understands the instructions? 1 "The bandages must be changed every day." 2 "I may have mild shoulder pain for approximately 1 week." 3 "The surgical sites should not be bathed for 1 week." 4 "I will remain on a full liquid diet for 2 more days.

2 Mild shoulder pain is common up to 1 week after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity during surgery. The response "The bandages must be changed every day" is not necessary; the bandages are removed on the second postoperative day. The response "The surgical sites should not be bathed for 1 week" is not necessary; the client may bathe and shower as usual. The response "I will remain on a full liquid diet for 2 more days" is not necessary; clients generally tolerate food between 24 and 48 hours postoperatively.

Which information would be included in the teaching plan for the older adult client with peptic ulcer disease who is taking an antacid and sucralfate? 1 Antacids should be taken 30 minutes before a meal 2 Sucralfate should be taken on an empty stomach 1 hour before meals. 3 Sucralfate is prescribed for the long-term maintenance of peptic ulcer disease. 4 Sodium bicarbonate is an inexpensive over-the-counter antacid with few adverse effects.

2 Sucralfate works best in a low pH environment; therefore it should be given on an empty stomach either 1 hour before or 2 hours after meals. Sucralfate also should be administered no sooner than 30 minutes before or after an antacid. The acid-neutralizing effects of antacids last approximately 30 minutes when taken on an empty stomach and 3 to 4 hours when taken after meals. When sucralfate and an antacid are both prescribed, they are each most effective when the sucralfate is scheduled an hour before meals and the antacid is scheduled after meals. Sucralfate is prescribed for the short-term treatment of peptic ulcers. Its use is limited to 4 to 8 weeks. The client should follow the recommendations of the primary health care provider with regard to antacid selection. Sodium bicarbonate can produce acid-base imbalances, which could be harmful, especially in older adult clients.

Which is a clinical manifestation of worsening preeclampsia? 1Polyuria 2Vaginal spotting 3Proteinuria of 3+ 4Blood pressure of 130/80 mm Hg

3 As preeclampsia worsens, blood pressure and edema increase and degenerative changes of the kidney cause increasing proteinuria (3+). With worsening preeclampsia, oliguria, not polyuria, is expected. Vaginal spotting is not a sign of worsening preeclampsia. A blood pressure of 130/80 mm Hg is within acceptable limits; however, there is insufficient information to determine whether it is increased in this client.

Which administration instruction would the nurse give a client prescribed ranitidine 150 mg daily to treat peptic ulcer disease (PUD)? 1 As needed 2 With meals 3 At bedtime 4 Before meals

3 Ranitidine is typically administered in a single dose at bedtime. This medication is used for 4 to 6 weeks in combination with other therapy; it is not used as needed, with meals, or when indigestion occurs.

Which are ways used to integrate evidence in the clinical practice setting? Select all that apply. One, some, or all responses may be correct. 1 Verbal mandates 2 Financial incentives 3 New assessment tools 4 Clinical practice guidelines 5 Organization policies and procedures

3,4,5 Evidence is integrated in a variety of ways through new assessment tools, clinical practice guidelines, organizational policies and procedures, new documentation tools, and teaching tools. Verbal mandates, or communicating mandatory behaviors verbally, are not an effective way to institute new evidence into clinical practice. Financial incentives have not been proven to be effective.

Which statement would the registered nurse include in the teaching plan regarding the proficient stage of Benner's five levels of proficiency? 1 "Work in the same clinical position for 2 to 3 years" 2 "Experience at some level with the situation" 3 "Ability to zero in on the problem and focus on managing care" 4 "Have more than 2 to 3 years of experience in the same clinical position"

4 The nurse would have more than 2 to 3 years of experience in the same clinical position in the proficient stage. In the competent stage, the nurse would be in the same clinical position for 2 to 3 years. In the advanced beginner stage, the nurse would have had some level of experience with the situation. In the expert level, the nurse would be able to zero in on the problem and focus on managing care.

For which complication is a client with gestational hypertension at risk?1Placenta previa 2Polyhydramnios 3Isoimmunization 4Abruptio placentae

4 Vasospasms of placental vessels occur because of increased blood pressure. As a result, the placenta may separate prematurely (abruptio placentae). Placenta previa is an abnormal placental implantation and is not related to hypertension. Polyhydramnios, an excessive amount of amniotic fluid, is not associated with hypertensive disorders of pregnancy. Isoimmunization in pregnancy is associated with Rh incompatibility, not hypertension.

One side effect of oxytocin stimulation is hypertonic contractions. The nurse knows this can be detrimental to the fetus for what reason? A It causes a reduction of placental blood flow B It produces a prolapsed cord C It increases maternal renal blood flow D It decreases maternal blood pressure

A

The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a drug in which classification? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor

d

During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? a. Hematemesis b. Pain when eating c. Melena d. Weight loss

c melena is dark tarry stools

Which information is correct regarding the similarities and differences between the deontological and utilitarianism system of ethics? Select all that apply. One, some, or all responses may be correct. 1 The difference between utilitarianism and deontology is the focus on outcomes. 2 Utilitarianism takes into consideration the usefulness of an action; deontology does not look into consequences. 3 Utilitarianism measures the effect that an act will have; deontology looks to the presence of principles regardless of the outcome. 4 Utilitarianism and deontology are closely related to the ethics of care because both ideologies promote a philosophy that focuses on understanding relationships. 5 Both utilitarianism and deontology look into the nature of relationships and propose that the natural urge to be influenced by relationships is a positive value.

1,2,3 The difference between utilitarianism and deontology is the focus on outcomes of the effects. Utilitarianism takes into consideration the usefulness of an action; deontology does not look into consequences. Utilitarianism measures the effect that an act will have; deontology looks to the presence of principles regardless of the outcome. Ethics of care and feminist ethics are closely related because both promote a philosophy that focuses on understanding relationships, especially personal narratives. Feminist ethics look into the nature of relationships and propose that the natural urge to be influenced by relationships is a positive value.

Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%? Select all that apply. One, some, or all responses may be correct. 1 Level of orientation 2 Arterial blood gases 3 Bilateral lung sounds 4 Complete blood count 5 Pulmonary function test

2 Clients with COPD who have low oxygen levels respond to oxygen administration. However, some clients with COPD have a respiratory drive that stimulates breathing that is dependent on carbon dioxide. The administration of too much oxygen in these clients lowers respiratory drive and decreases breathing. Therefore, the nurse would assess the client's arterial blood gases to determine how much oxygen to administer. Level of orientation shows the amount of hypoxia the client is experiencing. Clients may have abnormal lung sounds that can impede oxygenation, but this is not the basis for determining oxygen administration. A complete blood count assesses red blood cells, hemoglobin, and hematocrit; these values can be diminished in clients with COPD, but they do not determine oxygen needs. Pulmonary function tests are used to diagnose pulmonary disorders.

A client with severe Crohn disease develops a small bowel obstruction. Which clinical finding would the nurse expect the client to report? 1 Bloody vomitus 2 Projectile vomiting 3 Bleeding with defecation 4 Pain in the left lower quadrant

2 Nausea and vomiting, accompanied by diffuse abdominal pain, commonly occur in clients with small bowel obstruction; the vomiting may be projectile and may contain bile or fecal material. Hematemesis is associated more closely with peptic ulcer disease. Bleeding with defecation is associated with hemorrhoids and anal fissures. Pain in the left lower quadrant is associated with diverticulitis. Pain associated with a small bowel obstruction usually is more diffuse.

BUBBLE HE assessment

Breasts- Have pt lie down and remove bra, palpate breasts for engorgement/nodules; inspect nipples for pressure, soreness, cracks, fissures Uterus- Top of uterus (fundus) remains firm, if not may have placental fragments, can lead to hemorrhage, gently massage to help muscles contract Bladder- Polyuria during first few days after delivery, watch for s/s of infection, note dysuria/retention Bowels- Assess for bowel sounds, encourage activity w/ rest periods, and adequate fluid intake Lochia- Fleshy scent, a fetid odor may mean infection Episiotomy- Midline sight of choice, for lateral position patient on affected side, instruct to flex top leg at knee and draw it up toward waist; use penlight, wear gloves, gently lift top buttock to expose area, assess for hemorrhoids Homan's Sign- Position legs flat on bed w/ she's in supine position; dorsiflex the foot toward ankle, once on each leg; if she reports calf pain, must assess for blood clot in leg Emotional Status- Consider 3 new mom phases 1. "Taking in", often sleeps, relives events surrounding birth 2. "Taking hold", preoccupied w/ present, concerned for herself and baby's condition, want to learn to care for baby 3. "Letting go", later in postpartum period, reestablishes relationships w/ others

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During an NST, the client asks what it means when the fetal heart rate goes up every time the fetus moves. Which is an appropriate response? 1"These accelerations are a sign of fetal well-being. "2"These accelerations indicate fetal head compression. "3"Umbilical cord compression is causing these accelerations "4"Uteroplacental insufficiency is causing these accelerations."

1 fetal well beingThe NST is performed before labor begins. Accelerations with movementand a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.

ptyalism

excessive salivation

Tachysystole

more than 5 contractions in 10 minutes

A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The client states, "I am now ready for the surgery to create an ileostomy." Which nursing intervention best meets the client's needs at this time? 1 Parenterally replace the client's fluids and electrolytes. 2 Adjust client's diet to promote weight gain. 3 Provide anticipatory teaching on the use of ileostomy appliances. 4 Encourage client interaction with other clients who have an ileostomy.

1 When a client has an ulcerative colitis exacerbation, the client may have more than 10 stools per day, and the stools are bloody and full of mucus. The client can become dehydrated and lose vital electrolytes. Parenterally replacing fluids and electrolytes is a life-saving strategy; replacement occurs before performing the surgery to stabilize the client. Helping the client regain former body weight is not the priority at this time. The client is neither physically nor cognitively ready to learn the psychomotor skill of how to manage an ileostomy. The client is not demonstrating a readiness for contact with other persons with ileostomies at this time.