Final Weeks Questions

C, D (pelvic rock = cat/cows) (Avoid A b/c sudden heat elevation can cause abnormal fetal development) (B is for perineal muscles, not backaches)

Which of the following measures could be taken to reduce backaches in a pregnant client? (SATA) a) Soak in hot tub once per day b) Perform kegel exercises 2x/day c) Perform pelvic rock exercises daily d) Position knees higher than hips when sitting e) Sleep in a supine position

A (restlessness indicates progressing well in labor) (therapeutic relationship)

A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful? a) Stand next to her at the side of the bed. b) Turn up the volume of the music playing in the room. c) Turn on the television as a focal point. d) Stand silently at the back of the room.

D (ABCs)

The nurse is assessing a client who experienced second- and third-degree burns of the arms and hands from a kitchen grease fire. After determining that the client did not experience an inhalation injury, which assessment should be completed next? a) pain assessment b) orientation c) extensiveness and depth of the burns d) blood pressure and heart rate

D

These pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first? a) a lethargic 15-month-old with pink cheeks whose parent reported temperature of 38.4°C (101.2°F) b) a pale 6-month-old with a frequent cough and audible wheezing c) a crying 3-year-old whose parent is holding a cloth on the child's head covering a scalp laceration d) a quiet 2-year-old with nasal flaring who is sitting in a tripod position

D (not B because probably noisy and need decreased stimuli)

Which is indicated when caring for a NB w/ neonatal abstinence synd? a) Position NB supine after feeding b) Place NB near nurse's station c) Stimulate NB regularly by playing music d) Swaddle NB and place side-lying for feeding

C

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched? a) Tell the mother that excessive analgesia in labor can cause this type of cry. b) Continue to monitor the infant periodically for changes in the cry. c) Notify the primary care provider because this may indicate a neurologic problem. d) Stimulate the neonate to cry to obtain information to document.

D (this procedure is performed for pt with PAD) (A would be correct if in dependent position, not elevated)

Which finding is expected for a pt when completing the admission assessment of a pt who is scheduled for peripheral bypass surgery on the L) leg. Which of the following findings should the nurse expect? a) Rubor on the pt's affected leg when affected b) 3+ dorsal pedal pulse on the pt's left foot c) Increased hair on pt's client's left calf d) Report of intermittent claudication in the pt's affected leg

A (throat very narrowed!)

A child is being seen in the emergency department for reports of severe sore throat, trouble swallowing, and fever. The child has swollen cervical lymph nodes and a fiery red pharynx on examination. Which assessment findings below should be reported immediately to the healthcare provider? a) drooling and not swallowing b) coughing and sneezing c) loud snoring and noisy respirations d) sudden onset of ear pain

D

A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tube is accidentally pulled out of the chest wall. What should the nurse do first? a) Auscultate the lung to determine whether it collapsed. b) Instruct the client to cough to expand the lung. c) Immerse the tube in sterile water. d) Apply an occlusive dressing such as petroleum jelly gauze.

C

A client has been receiving total parenteral nutrition (TPN) for the last 5 days. Before discontinuing the infusion, the infusion rate is slowed. What complication of TPN infusion should the nurse assess the client for as the infusion is discontinued? a) essential fatty acid deficiency b) malnutrition c) rebound hypoglycemia d) dehydration

A

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? a) "You are not allowed anything by mouth so that your pancreas can rest." b) "Activity is important, so you will be scheduled for physical therapy." c) "I can offer you ibuprofen for pain with a small sip of water." d) "I will be starting antibiotic therapy once the blood cultures are obtained."

C

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? a) blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute b) urine output of 15 ml/hour and 2+ hematuria c) blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute d) urine output of 150 ml/hour and heart rate of 45 beats/minute

D

A client with an extracapsular hip fracture is scheduled for surgical internal fixation with the insertion of a pin. What can the nurse tell the client about the reason for this type of treatment for the fracture? a) Neurovascular impairment risk is decreased. b) Hemorrhage at the fracture site is prevented. c) The risk of infection at the site is lessened. d) The client is able to be mobilized sooner.

C

A RN is caring for a 5 lb 8 oz baby delivered 1 hour ago by a 19 yo primigravida. The priority nursing assessment includes monitoring for: a) Jaundice b) Bleeding c) Feeding and VS d) Apgar scores

D (estrogen can lead to increased RFR capillary bleeding so this is expected) (All others correct)

A RN is teaching about common discomforts during pregnancy. Which statement by the pt indicates further teaching is needed? a) "I should rest more often with my feet up, esp if I develop varicose veins in my legs" b) "It helps to lie down on my side when I start to feel dizzy and lightheaded" c) "I need to stop drinking so much fluid before I go to bed at night" d) "I should call my doctor if I develop a nosebleed or my gums start to bleed"

C

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first? a) the risk manager b) the pharmacist c) the prescriber d) the client

A (was able to rule out C b/c question specifically states perineal pain! Vaginal laceration would have s/s of trickle of lochia rubra)

On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for which complication? a) perineal hematoma. b) puerperal infection. c) vaginal lacerations. d) history of drug abuse.

D (Developmentally appropriate activities and therapeutic play encouraged)

The parent brings a child to the clinic after discharge from the hospital for Guillain-Barré syndrome. Which statement by the parent indicates that the discharge plan is being followed? a) "She and her sister argue all day." b) "She has missed a few of her therapy sessions because she often sleeps." c) "I have to bribe her to get her to do her exercises." d) "I take her to the pool where she can exercise with other children."

A (is an opioid antagonist and helps pt stay drug free)

The family of a client in rehabilitation following heroin withdrawal asks a nurse why the client is receiving naltrexone. What is the nurse's best response? a) to help reverse withdrawal symptoms b) to decrease the client's memory of the withdrawal experience c) to keep the client sedated during withdrawal d) to take the place of detoxification with methadone

D (B would be amniotic fluid acid determination)

The health care provider prescribes a maternal blood test for alpha fetoprotein for a nulligravid client at 16 weeks' gestation. When developing the teaching plan, the nurse bases the explanations on the understanding that this test is used to detect which condition? a) Rh incompatibilities b) inborn errors of metabolism c) Lecithin-sphingomyelin ratio d) neural tube defects

A (b/c GERD worsens with overdistension of stomach)

Which would be most helpful in management of GERD? a) Eat small frequent meals b) Increase fluid intake c) Avoid swallowing air with meals d) Add a bedtime snack to the dietary plan

C

The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition? a) increased intensity of contractions b) fetal head engagement c) prolapsed cord d) a need for an analgesic medication

B (A would be general anesthesia)

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that a) the infant's reflexes will be decreased or absent. b) the infant should respond to gentle tactile or verbal stimulation. c) the infant will remember the procedure. d) the infant will need a patient-controlled analgesia (PCA) pump during sedation.

A, D (C would be right if hyporeflexia. Remember, Mg does opp of prefix.) (D is SE but not s/s of toxicity)

Which are s/s of Mg sulfate IV toxicity? (SATA) a) RR less than 12 b) Excessive UOP c) Hyperreflexic DTRs c) Decreased LOC d) Flushing and sweating

Warfarin

Which anticoag is CI in pregnancy?

A, B, E

Which would be allowed on a clear liquid diet? a) Plain coffee b) Grape juice c) Nonfat milk d) Custard e) Lemon gelatin

B (should hang freely)

The nurse is caring for a client with a fractured fibula who has skeletal traction and skeletal pins. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? a) The client is reporting pain and muscle spasm. b) The traction weights are resting on the floor. c) The client wants to change position. d) There is a small amount of clear fluid at the pin sites.

D (Mec asp allows air to enter the lungs, but not exist, causing alveolar overdistension --> could lead to alveolar rupture = pneumo)

A baby developed mec aspiration synd and has an Apgar below 6, has pallor, apnea, cyanosis, barrel-shaped chest and a slow HR. Which of the following is true about this condition? a) Alveoli are under-distended b) Hypoinflation of the lungs occurs c) Air is not allowed into lungs d) Pneumothorax may occur

A

A client with gestational hypertension receives magnesium sulfate 50% 4 g in 250 mL D5W over 20 minutes. What priority assessment should the nurse perform when administering this drug? a) deep tendon reflexes b) temperature c) fetal heart rate d) intake and output

A, C, E

A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When the nurse informs the client that the physician has ordered a wound care nurse to examine the wound, the client asks why should anyone other than the staff nurse care for the wound. The client states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." Which responses made by the nurse would be appropriate? Select all that apply. a) "The wound nurse is specially trained to care for diabetic wounds." b) "Do you want me to tell the physician you refused?" c) "You could possibly lose your foot without proper care." d) "This is a big deal, and you need to recognize how serious it is." e) "We're very concerned about your foot and we want to provide the best possible care for you."

A (pt who has impaired consciousness or altered mental status is at increased risk for injury from heating pad)

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? a) Client's level of consciousness b) Client's vital signs and breath sounds c) Client's nutritional status d) Client's risk for falls

B

A pt has been in hospice for several weeks. His death is expected within the next several hours. Which intervention is most appropriate at this time? a) Support his wish to d/c curative tx b) Encourage loved ones to remain with pt c) Help pt overcome any feelings of inadequacy d) Reduce pt's fear of being a burden on his family

C

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client? a) changing the catheter site dressing every shift b) assessing capillary refill time c) assessing for sensation in the legs d) keeping the client flat in bed

B (C would increase rate and cause further cramping) (would do A if cramping continues)

The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first? a) Clamp the tubing, and carefully withdraw the tube. b) Temporarily stop the infusion, and have the client take deep breaths. c) Raise the height of the enema container. d) Rub the client's abdomen gently until the cramps subside.

A (older pregnant women more likely to develop gestational HTN)

The nurse is assessing a 39-year-old client during her 32-week prenatal checkup. The client has attended regular prenatal checkups throughout the pregnancy. Which assessment data is a priority for the nurse to complete? a) blood pressure b) iron and ferritin levels c) urine ketones d) sexually transmitted infection (STI) screening

C (heat for stiffness, ice for pain)

The nurse is developing a plan of care for a client who has joint stiffness due to rheumatoid arthritis. Which measure will be the most effective in relieving stiffness? a) aspirin after activity to decrease inflammation b) cold compresses to joints for 30 minutes to relieve stiffness c) a warm shower before performing activities of daily living d) a 10-lb (4.5-kg) weight loss to limit stress on joints

B (think of lying down with GERD)

The nurse would expect a client with a hiatal hernia to report that the symptoms worsen when the client is: a) physically active. b) lying down. c) sitting. d) upset or angry.

A

What is the best position to improve oxygen saturation in a pt with hypoxemia and R) sided PNA? a) L) side down b) R) side down c) Semi fowlers d) High fowlers

A (clear liquids don't always have to be colorless... apple, cranberry and grape juice accepted. Also black coffee, broth, plain gelatin)

Which item is approved on a clear liquid diet? a) Grape juice b) Lemon sherbert c) Chocolate milk d) Vanilla ice cream

C

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the: a) severe head injury and no blood pressure. b) lumbar spinal cord injury and lower extremity paralysis. c) maxillofacial injury and gurgling respirations. d) second-trimester pregnancy in premature labor.

C

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome? a) The client is in need of a dextrose solution containing normal saline solution for gradual rehydration. b) The client is fluid overloaded and needs I.V. fluid slowly to prevent circulatory overload and collapse. c) The client is severely dehydrated and needs 2 to 3 L of I.V. fluid rapidly. d) The client is severely dehydrated and needs 10 L of I.V. fluid over the first 24 hours.

A, B, D (obtain U/A to check for hemolysis)

A RN is transfusing PRBC to a pt who has anemia. The pt reports a fever and reports sudden h/a and chills. In addition to notifying the MD, what should the RN do? a) stop the transfusion b) remove blood bag and tubing from IV catheter c) Discard the blood container and tubing in a biohazard receptacle d) Obtain a urine specimen e) Infuse dextrose 5% in water through IV

E, C, D, B, A (maslow's = physiological need greater than psych need)

A RN working in the ED has been assigned the following tasks. Which order should they be completed? a) Complete incident report for pt who fell in hallway b) Administer alprazolam to a pt who is very anxious c) Start an IV on a pt who is fluid volume depleted d) Transport a pt for a radiograph of a splinted forearm e) Start a nebulizer tx on a pt with a prolonged asthma attack

D

A nurse preceptor is observing a new graduate nurse during care of a client in contact isolation. What action by the new graduate indicates the need for further teaching about handling the client's soiled linens? a) wears gloves when handling the client's soiled linen b) disposes of soiled linen before exiting the client's room c) places blood-soaked linen in the room's biohazard container d) uses alcohol gel to clean hands after removing gloves

A (want to limit the spread of unknown toxins)

A toxic substance was released in a crowded stadium. Multiple pt transported to the facility - which action should the RN take first? a) Pv cross contamination of clients b) Complete a thorough pt assessment c) Tx pt arriving who have yellow triage tags d) Maintain a client tracking system

A (s/s of neuro impairment) (D may be due to not being used to cast yet)

After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom? a) inability to extend the fingers on the right hand b) vomiting after the cast is applied c) coolness and dampness of the cast after 5 hours d) fussiness and reports that the cast is heavy

B (D wrong b/c D is part of B so B is more comprehensive/complete answer)

An adolescent is at risk for injury related to intracranial pathology following a motor vehicle collision. Which nursing action is the priority? a) monitor oxygenation and temperature b) monitor intracranial pressure c) maintain normoglycemia and normotension d) maintain the head in a neutral position

D

When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers? a) a client who ambulates 4 times a day b) a client with an indwelling urinary catheter c) a client with an elevated white blood cell count d) a client who has a decreased serum albumin level

D (may be r/t decreased fluid intake, inactivity, etc)

Which GI s/s are you most likely to see in a pt one day after an uncomplicated vaginal delivery? a) Abd pain b) Diarrhea c) GERD d) Constipation

A

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)? a) obtaining vital signs during blood administration b) teaching a client receiving warfarin about follow-up care c) taking a telephone order for pain medications for a postoperative client d) assessing the hip wound during a dry sterile dressing change

C (b/c not competent)

Which client cannot sign out against medical advice? a) a pregnant 15-year old with vaginal spotting b) an adult client with ST elevation on the electrocardiogram c) a client who drank a bottle of vodka 1 hour ago d) a minor who has been emancipated by court order

D (big RF infective endocarditis)

Which client has a need for prophylactic antibiotic therapy prior to dental manipulations? a) the client who had a TKR (total knee replacement) one year ago b) the client who had a left THR (total hip replacement) 3 months ago c) the client who had an in ICD (implantable cardiac defibrillator) 2 weeks ago d) the client who had an aortic valve replacement 5 years ago

C (mannitol decreased ICP by moving intracellular fluid to extracellular space.... this can cause FVO in pt with HF)

Which dx is a CI for mannitol? a) Cerebral edema b) Oliguria c) HF d) Increased intraocular pressure