Midterm Capstone

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4. Leaving the rate of the heparin infusion as is

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?

Activate the emergency response plan.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement?

Administer oxygen at 8 to 10 L/min via face mask.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask.

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?

Administer short-duration insulin intravenously

The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client?

Administer the iron through a straw.

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents?

Administer the iron through a straw.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?

At least 30 minutes before exposure to the sun

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Audible stridor

The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet?

Bowel sounds

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Bright red blood and mucus in the stools

A postoperative client has been placed on a clear liquid diet. The nurse provides the client with which items that are allowed to be consumed on this diet? Select all that apply: 1) Broth 2) Coffee 3) Gelatin 4) Pudding 5) Vegetable juice 6) Pureed vegetables

Broth, Coffee, Gelatin

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

You will need to bottle-feed your newborn

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50 mm Hg (50 mm Hg)

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply *peas *raisins *potatoes *cantaloupe *cauliflower *strawberries

raisins, potatoes, cantaloupe, strawberries

A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do?

Eat a small box of raisins or drink a cup of orange juice before soccer practice.

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency?

Electrocardiographic changes

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

Elevating the affected arm on a pillow above heart level

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

Isoniazid plus rifampin (Rifadin) will be required for 9 months.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the health care provider.

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action?

Notify the primary health care provider (PHCP)

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

Notify the primary health care provider (PHCP).

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?

Notify the primary health care provider (PHCP).

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?

Notify the primary health care provider (PHCP).

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which action should the nurse perform immediately?

Notify the surgeon

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the healthcare provider who prescribed the medication if which condition is documented in the client's medical history?

Peripheral vascular disease

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client's medical record.

Place the normal report in the client's medical record

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

Polyuria

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply.

Polyuria Bone pain

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-yearold child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?

Positive

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Positive culture results

The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?

Possible sexual abuse

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL. Which patterns would the nurse watch for on the electrocardiogram? Select all that apply *U waves *Widened T wave *Prominent U wave *Prolonged QT interval *Prolonged ST segment

Prolonged QT interval, Prolonged ST segment

The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Restrict fluid intake. Give meperidine, 25 mg intravenously, every 4 hours for pain.

The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure?

Restrict fluids as prescribed.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration.

Rhythmic respirations with periods of apnea

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

Rice

A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician?

The client complains of a headache and blurred vision

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30cm. How should the nurse interpret this finding?

The client is measuring normal for gestational age

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

The client is probably hyperventilating.

A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6 C (99.6 F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical drainage

Urinary output of 20 mL/hr

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine Tenderness

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the primary health care provider if which diagnosis is documented in the client's history?

Venous thromboembolism

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition?

Vomiting following cancer chemotherapy

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?

What can I do for you?"

A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?

When drawing blood for electrolyte level testing

The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice?

White sacs attached to the hair shafts in the occipital area

The nurse is teaching a client with diabetes mellitus how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

Withdraws the NPH insulin first

The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?

Withhold the medication and call the PHCP, questioning the prescription for the client

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

- inhalation of bacterial spores -through a cute or abrasion in the skin -ingestion of contaminated undercooked meat

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?

Administer oxygen, 8 to 10 L/ minute, by face mask

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?

Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.

A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment?

Checking the frequency and consistency of bowel movements

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis

A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

Pulmonary function studies

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse?

White blood cell count of 3000 mm3 (3.0 × 109/L)

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit which of the following foods? 1) Apples 2) Bananas 3) Smoked salami 4) Steamed vegetables

smoked salami

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes the potassium level is 5.7mEq. Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? select all that apply

tall peaked t waves; widened QRS complexes

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?

"Did the child have a sore throat or fever within the last 2 months?"

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

"I ate shellfish about 2 weeks ago at a local restaurant."

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching?

"I can send my child to day care if he has a fever, as long as it is a low-grade fever."

The nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.

"I should decrease my oral fluids when I start this medication." "I should report headache and drowsiness to my doctor since these symptoms could be related to my desmopressin."

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's BEST response?

"It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

1.A primigravida with abruptio placenta 3.A gravida II who has just been diagnosed with dead fetus syndrome 5.A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply.

1.Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Positive pregnancy test

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn't have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as:

1.G = 3, T = 2, P = 0, A = 0, L =12.G = 2, T = 0, P = 1, A = 0, L =13. G = 1, T = 1. P = 1, A = 0, L = 14.G = 2, T = 0, P = 0, A = 0, L = 1

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 35 seconds. On the basis of the prothrombin time, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

2. Holding the next dose of warfarin

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.

2. Lesion is highly metastatic. 3. Lesion is a nevus that has changes in color

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply ?

3.The cervix is dilated completely. 5.The ferguson reflex is initiated from perineal pressure

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture

The nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is most likely at risk for a fluid volume deficient? *client with an ileostomy *client with heart failure *client on long-term corticosteroid therapy *client receiving frequent wound irrigations

A client with an ileostomy

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising

After a shower or bath

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?

Age younger than 50 years

Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply.

Alcohol Whole-grain cereals Carbonated beverages

A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication?

An episode of diarrhea

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

Attempt to arouse the client.

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?

Bacteriuria

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

Choking with feedings

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action

Contact the electrical maintenance department for assistance.

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

Continue to monitor the drainage.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety?

Convey empathy, trust, and respect toward the client

An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign?

Cough

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?

Cough

A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?

Crackles on auscultation of the lungs

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing

A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate being prescribed?

Deferoxamine

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client?

Encouraging fluid intake

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

Encouraging fluids

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?

Enlarged lymph nodes

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

Failure to pass meconium stool in the first 24 hours after birth

Which assessment following an amniotomy should be conducted first?

Fetal heart rate pattern

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.

Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply.

Fever Nausea Tremors Confusion

The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?

Fine grayish red lines

The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

Foul-smelling ribbon-like stools

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Fruity breath odor and decreasing level of consciousness

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield

A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?

Heartburn

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding?

Heavy

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

I will be sure to cue in to any indicators that the client may be exaggerating their pain.. Pain is a highly individual experience. Should not assume that the client is exaggerating his pain

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication?

IV fluids containing dextrose

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action?

Increase fluid intake to 2000 to 3000 mL daily.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 ° F. What is the priority nursing action?

Increase hydration by encouraging oral fluids

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions should the nurse anticipate receiving? Select all that apply.

Initiate an infusion of 3% NaCl Restrict fluids to 800 mL over 24 hours Administer a vasopressin antagonist as prescribed

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care?

Initiate bleeding precautions.

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?

Intratracheal

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply.

Leukocytosis Urinary output of 800 mL/hr Clear drainage on nasal dripper pad

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition?

Limited range of motion in the affected hip

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level? *Malnutrition *Renal insufficiency *Hypoparathyroidism *Tumor lysis syndrome

Malnutrition

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Metabolic Alkalosis

A 7-year-old child is seen in a clinic, and the pediatrician documents a diagnosis of nighttime (nocturnal) enuresis. The nurse should provide which information to the parents?

Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer?

Pain relieved by food intake

The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment?

Palpating the abdomen for a mass

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse contacts the primary health care provider before administering the medication if which disorder is documented in the client's history?

Pancreatitis

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition.

Patent ductus arteriosus

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?

Periorbital edema

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent non-reassuring fetal heart rate

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

Place the client in Trendelenburg's position.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in a semiprivate room at the end of the hallway.

A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10 to 11.1 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia?

Prednisone

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client?

Private room or cohort client

A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the serum level. Which food item does the nurse instruct the client to avoid. 1) Peas 2) Nuts 3) Cauliflower 4) Processed oat cereals

Processed oat cereals

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms?

Projectile vomiting

Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic

A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

Reduction of steatorrhea

A client who uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?

Relief of epigastric pain

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

Respiratory alkalosis, compensated

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?

Safely securing the safety device straps to the side rails

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

Side-lying

The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?

Small, blue-white spots with a red base found on the buccal mucosa

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

Teach the client and family about the need for hand hygiene.

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 70 mg/dL (3.9 mmol/L), temperature of 101° F (38.3° C), pulse of 82 beats per minute, respirations of 20 breaths per minute, and blood pressure of 118/68 mm Hg. Which finding would be the priority concern to the nurse?

Temperature

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?

Test the drainage for glucose

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

That the best time for the examination is after a shower

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs that the client that she should be able to find out the sex at 12 weeks' gestation because of which factor?

The appearance of the fetal external genitalia

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicated that the client is at risk for preterm labor?

The client has a hx of cardiac disease

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Triglyceride level

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?

Turn the child to the side.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the chart? *twitching *hypoactive bowel sounds *negative Trousseau's signs *hypoactive deep tendon reflexes

Twitching

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which patterns should the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply *U waves *absent P waves *inverted T waves *depressed ST segment *widened QRS complex

U waves, inverted t waves, depressed st segment

A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?

Uric acid level

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications?

Warfarin Glimepiride Amlodipine

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply.

a. Flushing b. Depressed respirations c. Extreme muscle weakness

Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided?

"Administer the antibiotics until they are gone."

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response should the nurse make?

"Antibiotics are not indicated unless a bacterial infection is present."

A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply.

1-Administer methimazole with food 3-Assess the client for unexplained bruising or bleeding 4-Instruct the client to report side and adverse effects such as sore throat, fever, or headaches.

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.

1-Feeling cold 2-Loss of body hair 3-Persistent lethargy 4-Puffiness of the face

The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The pediatrician has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriate response to the mother?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity."

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 1. Have one of the client's family members interpret 2. Have the Spanish-speaking triage receptionist interpret 3. Page an interpreter from the hospital's interpreter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client.

. Page an interpreter from the hospital's interpreter services.

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia

. Preventing and recognizing hyperglycemia

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement( s)? Select all that apply.

1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."**

The nurse is performing an assessment on a 10-year-old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply.

1. Abdominal pain 5. Painless, firm, and movable adenopathy in the cervical area

The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? Select all that apply.

1. Back 4. Soles of the feet 5. Palms of the hands

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which did the nurse observe?

2,4 Respirations that are abnormally deep, regular, and increased in rate

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription?

Intravenous infusion of normal saline

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease

Iron deficiency anemia

The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify?

Irrigating the nasogastric tube

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action?

Let the mother hold the child and direct the cool mist over the child's face.

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome?

Limit the fluids taken with meals

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?

Lying recumbent following meals

. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?

Maintain a patent airway

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

Malaise

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate?

Massage the fundus until it is firm

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus until it is firm

A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

Metabolic alkalosis

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation2. Respiratory alkalosis from anxiety and hyperventilation3. Metabolic acidosis from calcium loss due to broken bones4. Metabolic alkalosis from taking analgesics containing base products

Respiratory acidosis from inadequate ventilation

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

Normal saline infusion

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.

2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun 5.Examine your body monthly for any lesions that may be suspicious.

The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which problem? 1. A defect in the cochlea 2. A defect in the 8th cranial nerve 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex.

3. A physical obstruction to the transmission of sound waves

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. the nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid, twitching of the eyeballs. 2. A dorsiflexion of the ankle and great toe with fanning of the other toes. 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed. 4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference.

3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed.

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

3.Increased efficiency of contractions 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply.

4. Thinner and decrease in number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

A child of Mediterranean descent

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

A heart rate that is 90 beats per minute and irregular

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?

Fetal heart rate of 180 beats/minute

A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis?

Bone marrow biopsy showing blast cells

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?

Calcium level

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds.

An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication?

Confusion

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?

Conjunctival hyperemia

A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication?

Early morning

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Frequent swallowing

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which describes the sound of a heart murmur? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. Gentle blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

Gentle blowing or swooshing noise

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?

Hematuria

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemmorhage

Which purposes of placental functioning should the nurse include in a prenatal class? SELECT ALL THAT APPLY.

c. It is the way the baby gets food and oxygen. e. It provides an exchange of nutrient ms and waste products between the mother and developing fetus.

The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action?

Store the insulin in a dark, dry place.

After a tonsillectomy, the nurse reviews the surgeon's postoperative prescriptions. Which prescription should the nurse question?

Suction every 2 hours.

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside?

Suctioning equipment and oxygen

A client with hypertension has been told to maintain a diet low in sodium. A nurse who is teaching this client about foods that are allowed includes which food item in a list provided to the client? 1) Tomato Soup 2) Boiled Shrimp 3) Instant Oatmeal 4) Summer Squash

Summer Squash

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

Sweating and pallor

The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child?

Swimming

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's ,medication record and would contact the PHCP if the client is also taking which medication?

Vitamin A

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet? 1) Vitamin A 2) Vitamin B12 3) Vitamin C 4) Vitamin E

Vitamin B12

The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP?

Vomiting

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?

Pasta with sauce

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Reposition the infant frequently.

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching?

"I should consume less than 1 liter of fluid per day."

Which question should the nurse ask the parents of a child suspected of having glomerulonephritis?

"Has the child had a sore throat or a throat infection in the last few weeks?"

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

"I need to bring my infant back to the clinic in 1 month for a new cast."

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

"I should increase the fiber in my diet."

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching?

"I should lie on my back to perform the procedure."

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction?

"I should mix the medication in the baby food and give it when I feed my child."

The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate understanding of the proper way to take this medication? Select all that apply

"I should sit up for at least 30 minutes after taking this medication." "I should take this medication first thing in the morning on an empty stomach."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water."

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

"Lesions most often are located on the arms and chest."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction?

"I will clean up any spills from the diaper with diluted alcohol."

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which statement indicates that further teaching is needed about administration of the eye medication?

"I will flush the eyes after instilling the ointment."

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement, if made by the client, indicates a need for further education?

"I will maintain strict bedrest throughout the remainder of the pregnancy.

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?

"I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250 mg/dL (13.9 mmol/L)."

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother?

"The flowers from your garden are beautiful, but should not be placed in the child's room at this time."

Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?

"The medication is likely to cause stinging every time it is applied."

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?

"The medications will kill the bacteria and stop the acid production."

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence."

The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? 1) Cream of wheat, blueberries, coffee 2) Sausage and eggs, banana, orange juice 3) Bacon, cantaloupe, tomato juice 4) Cured pork, grits, strawberries, orange juice

1) Cream of wheat, blueberries, coffee.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.

2. Comatose state 3. Deep, rapid breathing 5. Elevated blood glucose level

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease.

1, 2, and 4

The nurse determines the client needs further instruction on cimetidine if which statements were made? Select all that apply.

1. "I will take the cimetidine with my meals." 2. "I'll know the medication is working if my diarrhea stops." 4. "Taking the cimetidine with an antacid will increase its effectiveness."

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)Select all that apply?

1. A client who has a history of intravenous drug use 3. A client who has a history of sexually transmitted infections

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply

1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes.

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.

1. Nuts 3. Liver 5. Lentils

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply.

1. Pallor 2. Edema 3. Anorexia 4. Proteinuria

The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply.

1. Pathological fracture 2. Urinalysis positive for Bence Jones protein 5. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2000 mm3 (2.0 × 109/L) 2. 5800 mm3 (5.8 × 109/L 3. 8400 mm3 (8.4 × 109/L) 4. 11,500 mm3 (11.5 × 109/L)

1.2000 mm3 (2.0 × 109/L)

Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent?

2 tablets

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.

2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 6. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults.

A client is diagnosed as having a intestinal tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply.

2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 2.0 mg/dL 4. Phosphorus level of 4.0 mg/dL

2. Potassium level of 3.0 mEq/L

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply.

2. Reduce exposure to environmental organisms. 3. Use strict aseptic technique for all procedures. 4. Ensure that anyone entering the child's room wears a mask.

A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day, and the client's weight is 7.2 kg. The pediatrician prescribes the digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the child at each dose?

28.8 mcg

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

A nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes which of the following on the list? 1) Oranges 2) Broccoli 3) Cream cheese 4) Broiled haddock 5)Luncheon meats

3,4,5

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.

3. Give the child a teaspoon of honey. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply.

3. The nurse who never had chickenpox 5. The nurse who never received the varicella-zoster vaccine

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3. Wheezes

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.

4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased CO2 2. An increased pH and a decreased CO2 3. A decreased pH and a decreased HCO3- 4. An increased pH with an increased HCO3-

4. An increased pH with an increased HCO3-

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L)

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?

A rigid, board-like abdomen

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?

A skin infection of the dermis and underlying hypodermis

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

A white color to the skin, which is insensitive to touch

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?

Abdominal distention

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/ minute

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure.

Rho (D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?

Being affected by Rh incompatibility

The nurse is caring for a child diagnosed with erythemia infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child?

An intense fiery red edematous rash on the cheeks

A client in preterm labor (31 weeks) who is dilated to 4 cm had been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?

Betamethasone

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?

Anti-streptolysin O titer

A topical corticosteroid is prescribed by the health care provider for a child with contact dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

Apply a thin layer of cream and rub it into the area thoroughly.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment?

Blood pressure

Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?

Apply the lotion to cool, dry skin at least 30 minutes after bathing

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Ask the client to extend the arms

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids, including juices

The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

Increase the frequency of ibuprofen.

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

Increased calcium level

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?

It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal

A mother brings her 2-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation?

It is negative.

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid to treat acne. The nurse determines that which client complaint may be associated with use of this medication?

Itching

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19 2020. Use Niagele's rule which expected date of delivery should the nurse document in the clients chart?

July 26 2021

A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: 1) Legume 2) Milk 3) Chicken 4) Broccoli

Legumes

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP).

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action?

Notify the health care provider (HCP).

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

On the stomach

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

The passage of flatus

A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease?

The presence of Reed-Sternberg cells in the lymph nodes

The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection?

Vastus lateralis

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

Thicken the feedings by adding rice cereal to the formula.

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

This is a normal, expected event

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Tinnitus

A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?

To bring the child to the clinic to be seen by the pediatrician

The nurse should tell the client who is taking levothyroxine to notify the primary health care provider (PHCP) if which problem occurs?

Tremors

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.

Tremors Irritability Hot, dry skin

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction?

Weighing the diapers

The nurse caring for a cleint who has been receiving IV diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a cleint with this condition? *weight loss and poor skin turgor *lung congestion and increased heart rate *decreased hematocrit and increased urine output *increased respirations and increased blood pressure

Weight loss and poor skin turgor

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result?

normal findings

A pediatrician prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant?

p24 antigen assay

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply

2. Routine administration of subcutaneousheparin may be prescribed. 3. An overbed lift may be necessary if the clientrequires a cesarean section. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply.

2. Shakiness 3. Palpitations 5. Lightheadedness

A client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?

"The best time for me to exercise is after breakfast."

The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information?

"The child does not experience pain at the primary tumor site."

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?

"The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement?

"This medication can be taken to prevent and treat clients with breast cancer."

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction?

"We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?

"You need to consult with the primary health care provider (PHCP) before receiving immunizations."

The nurse should make which statement to a pregnant client found to have gynecologist pelvis?

"Your type of pelvis is the most favorable for labor and birth."

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the clients lab report, should be reported before administering the dose of furosemide? *3.2 mEq/L *3.8 mEq/L *4.2 mEq/L *4.8 mEq/L

*3.2 mEq/L

On review of the client's medical records, the nurse determines that which client is at risk for fluid volume excess? *The client taking diuretics who has tenting of the skin *The client with an ileostomy from a recent abdominal surgery *The client who requires intermittent gastrointestinal suctioning *The client with kidney disease and a 12-year history of diabetes mellitus

*The client with kidney disease and a 12-year history of diabetes mellitus

A pediatrician's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4 mL." The nurse prepares to draw up how many milliliters to administer 1 dose?

0.925 mL

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1.Platelets 35,000 mm3 (35 × 109/L)2.Sodium 150 mEq/L (150 mmol/L)3.Potassium 5.0 mEq/L (5.0 mmol/L)4.Segmented neutrophils 40% (0.40)5.Serum creatinine, 1 mg/dL (88.3 mmol/L)6.White blood cells, 3000 mm3 (3.0 × 109/L)

1,2,4,6

The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

1,2,4,6

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.

1-Administer stool softeners as prescribed 2-Encourage a high-fiber diet to promote bowel movements without straining. 3-Apply cold packs to the anal-rectal area over the dressing until the packing is removed.

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.

1. Facial edema in the morning 3. Serum calcium level of 12 mg/dL (3.0 mmol/L) 6. Numbness and tingling of the lower extremities

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply.

1. Provide a soft diet. 5. Administer ibuprofen for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply.

1. Providing a low-fat, well-balanced diet. 2. Teaching the child effective hand-washing techniques. 5. Instructing the parents to avoid administering medications unless prescribed

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions? Select all that apply.

1. Radiation 2. Chemotherapy 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Adequacy of capillary filling

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area?

3

The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary?

"I can take aspirin or my antihistamine if I need it."

The nurse has given instructions to a client who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instruction?

"This medication should only be taken with water."

The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching?

"Take your prescribed pills 1 hour before or 2 hours after the injection."

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be MOST APPROPRIATE?

"Do you plan to have any other children?"

The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment?

"Has any family member had a sore throat within the past few weeks?"

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response?

"Have the child perform simple isometric exercises during this time."

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?

"I can use lotion or powder around the cast edges to relieve itching."

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?

"I empty the urinary collection bag when it is two-thirds full."

A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child?

"I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less."

The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching?

"I need to constantly watch for signs of low blood sugar."

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?

"I need to limit my intake of dietary fiber."

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?

"I need to stop my insulin."

The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?

"I noticed his urine was the color of cola lately."

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?

"I should apply lotion under the brace to prevent skin breakdown."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I should avoid exercise because of the negative effects on insulin production."

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction?

"I'll let him decide when to return to his play activities."

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?

"I'm glad I don't have to lie still for this procedure."

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

"I'm going to take aspirin for my headache as soon as I get home."

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

"If my child vomits after medication administration, I will repeat the dose."

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venous. Which statement by the student indicates an understanding of the ductus venousus?

"It connects the umbilical vein to the inferior vena cava."

The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?

"It is okay to share towels and washcloths."

A 55 year old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response?

"Please share with me more about your concerns."

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?

"Take a shower immediately, lathering and rinsing several times."

The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply.

1. Easy bruising occurs. 2. Gum bleeding occurs. 3. It is a hereditary bleeding disorder. 4. Treatment and care are similar to that for hemophilia. 6. The disorder causes platelets to adhere to damaged endothelium.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply

1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 5. Give hydromorphone intravenously as prescribed for pain

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

1. Monitor the child's weight. 2. Frequent hand washing is important. 3. The child should avoid exposure to other illnesses. 5. Clean up body fluid spills with bleach solution

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.

1. Place the infant in a private room. 3. Wear a mask, gown, and gloves when in contact with the infant. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply.

1. Stop the infusion. 2. Prepare to apply ice or heat to the site. 4. Notify the primary health care provider (PHCP). 5. Prepare to administer a prescribed antidote into the site.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

1. Time the seizure. 3. Stay with the child 5. Move furniture away from the child.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

1. Wear a supportive bra. 2. Rest during the acute phase 3. Maintain a fluid intake of at least 3000 mL 4. Continue to breast-feed if the breasts are not too sore

Atropine sulfate, 0.6 mg intramuscularly, is prescribed for a child preoperatively. The nurse has determined that the dose prescribed is safe and prepares to administer how many milliliters to the child? Fill in the blank (refer to figure).

1.5

Penicillin G procaine, 1,000,000 units IM (intramuscularly), is prescribed for an adolescent with an infection. The medication label reads "1,200,000 units per 2 mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the adolescent? Round answer to the nearest tenth position.

1.7 mL

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply

1.Age 54 2.Body mass index of 28 3. Previous difficulty with fertility

A client has been admitted to the hospital for Gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drop to which value? A. 3mg/dL B. 15mg/dL C. 29 mg/dL D. 35mg/dL

15mg

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.

2. Keep small toys and sharp objects away from the cast. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity.

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply.

2. Keeping pregnant women out of the client's room. 3. Placing the client in a private room with a private bath. 4. Wearing a lead shield when providing direct client care.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply

2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs.

The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1) Weight loss 2) Flat neck and hand veins 3) An increase in blood pressure 4) a decreased central venous pressure (CVP)

3) An increase in blood pressure Rational: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid colume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Options 1, 2, and 4 identify signs noted in fluid volume deficit.

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?

Assessing for the return of the gag reflex

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.

4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?

Call the Poison Control Center.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

Change the dressing as prescribed.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply.

Coffee Chocolate Peppermint Fried chicken

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?

Cover the bladder with a nonadhering plastic wrap.

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse would offer which full liquid item to the client? 1) Tea 2) Gelatin 3) Custard 4) Popsicle

Custard

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placentae is present. Based on these findings, the nurse would prepare the client for:

Delivery of fetus

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Document the findings.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

Fluid and electrolyte imbalance

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by then parents as a precipitating factor, indicates the need for further instruction?

Fluid overload

The nurse working in the emergency department is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? *Muscle twitches *Decreased urinary output *Hyperactive bowel sounds *Increased specific gravity of the urine

Hyperactive bowel sounds

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia?

Hypertension

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?

Hypertension

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?

Hyperventilation

A client with diabetes mellitus is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply

Hypoglycemia may be experienced before dinnertime. The insulin should be administered at room temperature.

A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply

Hypotension Hyperkalemia

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

I will need to increase my insulin dosage during the first 3 months of pregnancy."

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?

Inadequate fluid volume

A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?

Intravenous infusion of factor VIII

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?

Increased uric acid level

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

Inform the client that these contractions are common and may occur throughout the pregnancy

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.

Insomnia Weight loss Mild heat intolerance

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate?

Instruct the client to request help when getting out of bed.

The nurse is reading a primary health care provider's progress notes in the client's record and reads that PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? *urinary output *wound drainage *integumentary output *gastrointestinal tract

Integumentary output

Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy?

Measure the client's current weight and height.

The nurse has just administered ibuprofen to a child with a temperature of 102° F (38.8° C). The nurse should also take which action?

Remove excess clothing and blankets from the child.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a private room.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action?

Move the victim to a safe area away from the snake and encourage the victim to rest.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur?

Naloxone

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? *sustained tissue damage *requires nasogastric suction *history of addisons disease *uric acid level of 9.4 mg/dL

Nasogastric Suction

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and should contact the pediatrician to question which prescription?

Nasotracheal suction as needed

A client has an as-needed prescription for ondansetron. For which condition(s) should the nurse administer this medication?

Nausea and vomiting

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?

Notify the health care provider (HCP)

A nursing students needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? 1) Obtaining a controlled intravenous (IV) infusion pump 2) Monitoring urine output during administration 3) Preparing the medication for bolus administration 4) Diluting the medication in appropriate amount or normal saline

Obtain; monitor urine output, monitor iv site, ensure the medication is diluted; ensure that the bag is labeled.

The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way?

On an empty stomach

A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse should schedule the medication for which times?

One hour before meals and at bedtime

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

One week after menstruation begins

A client is recovering from abdominal surgery and has a large abdominal wound. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1) Milk 2) Oranges 3) Bananas 4) Chicken

Oranges

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which of the following from her menu? 1) Nuts and milk 2) Coffee and tea 3) Cooked rolled oats and fish 4) Oranges and dark green leafy vegetables

Oranges and dark green leafy vegetables

A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication?

Orthostatic hypotension

The nurse is assisting a primary health care provider (PHCP) examine a 3- week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess?

Ortolani's maneuver

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?

Partial thromboplastin time

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

Partial-thickness skin loss of the dermis

A client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication?

Peripheral neuropathy

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is most significant to review?

Prothrombin time

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures.

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?

Purple discoloration of the stoma

Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic

The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition?

The child consistently tilts the head to see.

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

The child is 18 months old

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out

The nurse is assessing a client for meningeal irritation and elicits a positive Brudinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column 4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

Which client is at risk for the development of a potassium level of 5.5 mEq/L? *the client with colitis *the client with cushing's syndrome *the client who has been overusing laxatives *the client who has sustained a traumatic burn

The client who has sustained a traumatic burn

Which client is at risk for the development of a sodium level at 130 mEq/L? *The client who is taking diuretics *The client with hyperaldosteronism The client with Cushing's syndrome *The client who is taking corticosteroid

The client who is taking diuretics

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action?

The client with lochia that is red and has a foul-smelling odor.

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

The client's pain rating

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?

The development of a vesicovaginal fistula

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent?

The inactivated influenza vaccine will be given yearly

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? SELECT ALL THAT APPLY.

a. "The ductus arteriosus allows blood to bypass the fetal lungs." b. "One vein carries oxygenated blood from the placenta to the fetus." d. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

The instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? SELECT ALL THAT APPLY.

a. Allows for fetal movement b. Surrounds, cushions, and protects the fetus c. Maintains the body temperature of the fetus d. Can be used to measure fetal kidney function

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply.

a. Respirations of 10 breaths/minute b. Urine output of 20 mL in an hour

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply.

a. Uterine hyper stimulation b. Late decelerations of the fetal heart rate

The nurse is giving report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. every 2 hrs 2. every 3 hrs 3. every 4 hrs 4. every 30 min

every 30 min