MOCK NCLEX Q
A client is scheduled for a renal arteriogram. No allergies are recorded in the client's medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used? A: hypoventilation B: psoriasis C: pruritus D: nausea
C The nurse should be alert for pruritus, which may indicate a mild anaphylactic reaction to the arteriogram dye. The client would have an increased respiratory rate. Nausea would be more likely with a food allergy or intolerance and would not be associated with a reaction to the dye. Psoriasis is a chronic condition triggered by a hyperimmune response.
A 15-year-old client who is 26 weeks pregnant has been admitted to the labor and delivery unit with reports of abdominal pain. Her parents want to speak with a nurse about her condition. How should the nurse respond? A: "I'll need a signed consent from your daughter to give you medical information." B: "The health care provider can give you more information without consent." C: "She will be OK. It's just a stomachache." D: "She is experiencing Braxton Hicks contractions and is too young to understand the difference between these contractions and labor pains."
A A pregnant minor is emancipated from her parents so she can make decisions for herself and her baby. Therefore, the client's right to confidentiality means that neither the nurse nor the health care provider may divulge medical information without a signed consent.
The nurse is caring for an elderly client who has experienced a sensorineural hearing loss. The nurse anticipates that the client will exhibit which symptom? A: difficulty hearing high-pitched sounds B: problems with speaking clearly C: inability to assign meaning to sound D: vertigo when changing positions
A: difficulty hearing high-pitched sounds The client with sensorineural hearing loss has difficulty hearing high-pitched sounds. Aging and ototoxicity are two causes of sensorineural hearing loss. The client's ability to speak is not affected. The client who cannot assign meaning to sound has central hearing loss. Vertigo is commonly an indication of an inner ear problem.
After teaching a pregnant client about potential complications of amniocentesis that must be reported immediately, the nurse determines that the client understands the instruction when she says that she will report which problem? A: urinary frequency B: vaginal bleeding C: nausea D: irregular, painless, uterine tightness
B Possible complications associated with amniocentesis include hemorrhage from penetration of the placenta, infection of the amniotic fluid, possible puncture of the fetus, and uterine irritation leading to premature labor. Therefore, after amniocentesis, the client should promptly report any vaginal discharge or bleeding, a decrease in fetal movement, or uterine contractions.Typically, nausea, urinary frequency, and irregular, painless, uterine tightness are not complications of amniocentesis.
A woman is taking oral contraceptives. The nurse teaches the client to report which complication? A: mild headache B: severe calf pain C: weight gain of 3 lbs D: breakthrough bleeding
B Women who take oral contraceptives are at increased risk for thromboembolic conditions. Severe calf pain needs to be investigated as a potential sign of deep vein thrombosis. Breakthrough bleeding, mild headache, or weight gain may be common benign side effects that accompany oral contraceptive use. Clients may be monitored for these side effects without a change in treatment.
Which statement indicates that the client who has undergone repair of the nasal septum has understood the discharge instructions? A: "I shouldn't shower until my packing is removed." B: "I will take stool softeners and modify my diet to prevent constipation." C: "Coughing every 2 hours is important to prevent respiratory complications." D: "It's important to blow my nose each day to remove the dried secretions."
B: "I will take stool softeners and modify my diet to prevent constipation." Constipation can cause straining during defecation, which can induce bleeding. Showering is not contraindicated. The client should take measures to prevent coughing. The client should avoid blowing the nose for 48 hours after the packing is removed. Thereafter, the client should blow the nose gently using the open-mouth technique to minimize bleeding in the surgical area.
When caring for a client with preeclampsia during labor, the nurse should: A: give a fluid bolus before the second stage of labor. B: give extra fluids throughout labor. C: restrict the amount of fluid administered. D: refrain from administering any fluids during labor.
C: restrict the amount of fluid administered. The volume of fluids administered during labor to a client with preeclampsia should be restricted. Clients usually receive between 60 and 150 ml/hour.
A child brought to the hospital with ketoacidosis is to receive regular insulin via an IV infusion. Which IV solution should the nurse expect the primary care provider to prescribe initially? A: 2.5% dextrose B: 5% dextrose C: 0.45% saline D: 0.9% saline
D: 0.9% saline A child with ketoacidosis has elevated blood glucose levels. Therefore, the child should initially receive normal saline solution because it is isotonic and does not contain glucose. The child receives this solution until the blood glucose level approaches the normal range. The rate, or units given per hour, is based on the child's weight. Solutions of 0.45% saline, 2.5% dextrose, and 5% dextrose are not used because their glucose content would only further elevate the child's glucose levels.
An overweight adolescent has been diagnosed with type 2 diabetes. What should the nurse do to increase the client's self-efficacy to manage the disease? A: Provide the client with a written daily food and exercise plan. B: Discuss eliminating junk food in the home with the parents. C: Arrange for the school nurse to weigh the child weekly. D: Utilize a peer with type 2 diabetes to role model lifestyle changes.
D: Utilize a peer with type 2 diabetes to role model lifestyle changes. Self-efficacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-efficacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client.
What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? A: preservation of muscle mass B: prevention of bone demineralization C: increase in muscle tone D: maintenance of joint mobility
D: maintenance of joint mobility The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone.
For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? A: Deficient fluid volume B: Impaired urinary elimination C: Imbalanced nutrition: Less than body requirements D: Excess fluid volume
A Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.
A nurse is caring for a 9-year-old child with a grave prognosis after sustaining a closed-head injury. The child is on mechanical ventilation without spontaneous respirations. What is the nurse's highest priority related to the potential for organ donation? A: discussing the decision about donation with the parents B: initiating referral to a transplant coordinator as soon as possible C: asking parents to contact the transplant service regarding donation D: contacting the family's spiritual leader for a discussion about donation
B: initiating referral to a transplant coordinator as soon as possible The transplant coordinator is the best health team member to approach the family about organ donation. Therefore, it is the nurse's priority obligation to make the referral to the transplant coordinator as soon as possible. The transplant coordinator is typically available to hospitals that routinely perform organ transplants. Pastoral care staff members provide emotional and religious support and are not involved with approaching the family about organ donation; they may, however, be present in a supportive capacity if the family wishes.
A 25-year-old client tells the nurse that she would like to become pregnant, but she has been diagnosed with blocked fallopian tubes due to pelvic inflammatory disease. When helping the client explore infertility treatment options, what is most appropriate for this client? A: gamete intrafallopian transfer B: zygote intrafallopian transfer C: menotropin therapy D: in vitro fertilization
D: in vitro fertilization Because this client's tubes are blocked, in vitro fertilization would be the most appropriate. After ova are removed surgically from the client and fertilized outside the uterus, the fertilized ova are introduced vaginally through a special tube through the cervix to the uterus for implantation, completely bypassing the fallopian tubes. Gamete intrafallopian transfer, the transfer of ova into a patent fallopian tube for fertilization, would be inappropriate for client with blocked fallopian tubes. Zygote intrafallopian transfer involves oocyte retrieval then fertilization. After fertilization, the fertilized eggs are transferred into the client's fallopian tubes. This is not an option for a client who has blocked tubes. Menotropin therapy would be appropriate if the client was experiencing ovarian dysfunction.
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? A: stage II pressure ulcer B: stage III pressure ulcer C: stage I pressure ulcer D: stage IV pressure ulcer
A A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of non-blanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.
A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is starting the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which client? A: middle-aged stable client with bladder cancer awaiting surgery B: middle-aged client who had a kidney transplant 3 days ago C: elderly client just admitted for an acute stroke B: client who had an ileal conduit 3 days ago
A The charge nurse should assign the new nurse to the middle-aged client newly diagnosed with bladder cancer awaiting surgery, as this client has a condition common to the genitourinary floor and is of low acuity and stable. The charge nurse should assign the agency nurse to the client who had an ileal conduit. That condition has lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient.
A client is voiding small amounts of urine every 30 to 60 minutes. What should the nurse do first? A: Encourage an increased fluid intake. B: Palpate for a distended bladder. C: Obtain a urine specimen for culture D: Catheterize the client for residual urine.
B When a client voids frequent, small amounts, the nurse should suspect that the client is retaining urine. Palpating for a distended bladder is the first assessment that the nurse should perform to verify this suspicion. Obtaining a prescription to catheterize for residual urine may be appropriate as a follow-up activity. Obtaining a urine specimen for culture is not a first priority. The nurse would not encourage an increased fluid intake until further assessment of the situation is completed.
The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. What should the nurse do next? A: Continue monitoring as usual; this is expected. B: Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system. C: Decrease the suction and continue observing the system for changes in bubbling during the next several hours. D: Notify the health care provider (HCP).
B: Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system. There should never be constant bubbling in the water-seal system; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction will not reduce the leak. It is not necessary to notify the HCP until the system has been checked and the problem identified.
Which adverse effect occurs when there is too rapid an infusion of TPN solution? A: hypoglycemia B: hypokalemia C: circulatory overload D: elevated blood urea nitrogen concentration
C Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.
A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions? A: The client will be free from anxiety and be able to use self-calming techniques before reaching panic level. B: The client will be oriented to person, place, and time. C: The client will show no self-harm or harm to staff. D: The client will be able to problem solve in situations on the psychiatric unit.
C The client is at increased risk for injury because of their hyperactivity, agitation, and disorientation. The goal for no self-harm or harm to staff best fits the priority for this situation. Although the client's anxiety and orientation is a concern and is important for the client's care, the client's safety always takes highest priority. The nurse should plan first and foremost to prevent injury and harm for which the client is at risk given their current condition.
A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? A: "Apply one applicator of terconazole intravaginally at bedtime for 7 days." B: "Apply one applicator of tioconazole intravaginally at bedtime for 7 days." C: "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." D: "Apply sulconazole nitrate twice daily by massaging it gently into the lesions."
C: "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times per day for 7 days. Terconazole and tioconazole treat vulvovaginal candidiasis. Sulconazole nitrate treats tinea versicolor.
Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain? A: 70 units of neutral protamine Hagedorn (NPH) insulin and 30 units of regular insulin B: 70 units of regular insulin and 30 units of NPH insulin C: 70% NPH insulin and 30% regular insulin D: 70% regular insulin and 30% NPH insulin
C: 70% NPH insulin and 30% regular insulin Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin.
A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The health care provider prescribes treatment with risperidone to improve the client's negative and positive symptoms of schizophrenia. When evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which symptom? A: apathy, affect, social isolation B: agitation, delusions, hallucinations C: hostility, ideas of reference, tangential speech D: aggression, bizarre behavior, illusions
A: apathy, affect, social isolation When determining the effectiveness of risperidone, the nurse would expect improvement in the client's negative symptoms of apathy, flat affect, and social withdrawal. Delusions, hallucinations, illusions, and ideas of reference are positive symptoms of schizophrenia. Agitation, hostility, and aggression are also the result of the positive symptoms.
The nurse teaches the mother of a child newly diagnosed with insulin dependent diabetes about the principles of a healthy eating plan. Which statement by the mother indicates effective teaching? A: "By spreading the calories throughout the day in small, frequent meals, the risk of hyperglycemia is eliminated." B: "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." C: "Snacks are used to offset the desire for sweets and to keep the meals smaller so my child can eat better." D:"Most children find it difficult to eat all the calories required by their diets in three main meals."
B Snacks are included in the diabetic diet to offset periods of peak insulin action. Because of the lack of pancreatic functioning, the child does not receive differing amounts of insulin in response to the glucose level in the bloodstream. The child with diabetes mellitus is given insulin at specific times; dietary intake must be matched to the insulin peaks and troughs.
A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)? A: Ask what medications the client is taking. B: Complete a history and health assessment. C: Identify the time of onset of the stroke. D: Determine if the client is scheduled for any surgical procedures.
C: Identify the time of onset of the stroke. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.
When developing the discharge plan for a child who had a nephrectomy for a Wilms' tumor, the nurse identifies outcomes to prevent damage to the child's remaining kidney and to accomplish which goal? A: Minimize pain. B: Prevent dependent edema. C: Prevent urinary tract infection. D: Minimize sodium intake.
C: Prevent urinary tract infection. Because the child has only one kidney, measures should be recommended to prevent urinary tract infection and injury to the remaining kidney. Severe pain and dependent edema are not associated with surgery for Wilms' tumor. Dietary sodium is not restricted because function in the remaining kidney is not impaired.
An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse's priority should be the potential for A: hyperglycemia. B: fluid volume excess. C: aspiration. D: constipation.
C: aspiration. Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake. Hyperglycemia is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation is a problem, but it usually isn't a serious one. The client would most likely experience diarrhea.
A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an IV infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? A: carefully titrating the oxytocin based on the client's pattern of labor B: monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes C: instructing the client to ambulate as tolerated D: helping the client use breathing exercises to manage her contractions
C: instructing the client to ambulate as tolerated Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate without restriction. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include in the care plan.
The nurse is performing a digital rectal examination. Which finding is a key sign for prostate cancer? A: a boggy, tender prostate B: A nonindurated prostate. C: abdominal pain D: a hard prostate, localized or diffuse
D On digital rectal examination, key signs of prostate cancer are a hard prostate, induration of the prostate, and an irregular, hard nodule. Accompanying symptoms of prostate cancer can include constipation, weight loss, and lymphadenopathy. Abdominal pain usually does not accompany prostate cancer. A boggy, tender prostate is found with infection (e.g., acute or chronic prostatitis).
The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best? A: Allow her to send out for her favorite foods. B: Allow her to enter the unit's kitchen for extra food as necessary. C: Serve the client food in small, attractively arranged portions. D: Serve foods that the client can carry with her.
D Because the client is very active, it would be best to give her food she can carry with her and eat as she moves. Neither allowing the client to send out for her favorite foods nor serving food in small, attractively arranged portions will address her need to be active. Allowing the client in the unit kitchen is impractical, and she most likely would be too busy to eat anyway.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? A: platelet count, prothrombin time, and partial thromboplastin time B: platelet count, red blood cell count, and hemoglobin C: thrombin time, fibrinogen, and hemoglobin level D: D-dimer, red blood cell count, and partial thromboplastin time
A The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, fibrinogen level, and D-dimer, as well as client history and other assessment factors. Red blood cell count and hemoglobin are not utilized in this diagnosis.
A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? A: I.V. tubing with a volume-control chamber B: I.V. tubing with a macrodrip chamber C: I.V. tubing with a special filter D: standard I.V. tubing used for adults
A: I.V. tubing with a volume-control chamber Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused.
An adult male client has been unable to void for the past 12 hours. What is the best method for the nurse to use when assessing for bladder distention in a male client? A: Determine rebound tenderness below the symphysis. B: Palpate for a rounded swelling above the pubis. C: Dullness in the lower left quadrant. D: Inspect the urethral meatus for urine discharge.
B The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. This swelling represents the distended bladder rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder. The client might experience tenderness or pressure above the symphysis. No urine discharge is expected; the urine flow is blocked by the enlarged prostate.
The client with recurrent depression and suicidal ideation tells the nurse, "I can't afford this medicine anymore. I know I'll be okay without it." What should the nurse do next? A: Inform the health care provider (HCP) of the client's statement. B: Ask the social worker to find financial assistance for the client. C: Schedule a follow-up appointment in 3 months. D: Ask the client whether a family member could help.
B The client needs to continue the medication without interruption to minimize the chance of decompensation. Because the client is in danger of noncompliance with the medication due to financial concerns, the nurse should contact the social worker to assist with locating resources for the client. Although the HCP is responsible for prescribing the client's medication, the HCP is not routinely involved in finding financial assistance for a client's medication needs. Scheduling a follow-up appointment in 48 hours does not address the client's immediate need for the medication; the client could stop the medication before being seen and become severely depressed. A family member's assistance may not be a sufficient, a permanent, or an appropriate means of financial help for this client.
A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a swallowing assessment? A: respiratory therapist B: speech therapist C: physical therapist D: physician
B The diagnosis and treatment of dysphagia (swallowing problems) is within the purview of speech therapists. The physician should be made aware and respiratory therapy may be involved with assessing and promoting the client's oxygenation but swallowing assessment is a task most often performed by a speech therapist.
During a routine prenatal visit, a pregnant client reports heartburn. To minimize her discomfort, the nurse should include which suggestion in the care plan? A: take sodium bicarbonate B: eat small, frequent meals C: drink more citrus juices D: limit fluid intake
B To relieve heartburn, the nurse should advise a pregnant client to eat smaller meals at shorter intervals; drink six to eight 8-oz glasses of fluid daily to minimize regurgitation and reflux of stomach contents; avoid citrus juice, which may act as a gastric irritant and worsen heartburn; and avoid sodium bicarbonate, which may disrupt the body's sodium-potassium balance.
The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730? A: Legally the medication has to be given at the prescribed time. B: The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made. C: The postoperative dose of cefazolin needs to be started exactly 8 hours after the preoperative dose of cefazolin. D: The peak and titer levels are needed for antibiotic therapy.
B: The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made. The antibiotic is most effective in preventing infection, according to research, if it is given 30 to 60 minutes before the operative incision is made. When the surgeon prescribes the antibiotic to be given at a specific time related to the scheduled time of the surgical procedure, it is imperative that the antibiotic is given on time. Legally, the nurse considers 30 minutes on either side of the scheduled time to be acceptable for administering medications; however, in this situation, giving the antibiotic 30 minutes too soon can make the prophylactic antibiotic ineffective. The postoperative dose of antibiotic is not timed according to the preoperative dose. Peak and titer levels are measured for some antibiotics, but in this case the primary reason is to have the antibiotic infused before the time of the incision.
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? A: active phase B: latent phase C: expulsive phase D: transitional phase
B: latent phase The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? A: decrease pulse rate B: dilated, fix pupils C: decreased LOC D: widening pulse pressure
C A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.
While assessing a 2-hour-old neonate, a nurse observes the neonate to have acrocyanosis. Which nursing action should be performed first? A: Immediately take the newborn's temperature according to hospital policy B: Notify the health care provider of the need for a cardiac consult. C: Do nothing different because acrocyanosis is normal in the early neonatal period. D: Give the baby a warm bath.
C Acrocyanosis, or bluish discoloration of the hands and feet in the early neonatal period is a normal finding and should not last more than 24 hours after birth. The other choices are inappropriate for this condition.
A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for: A: exophthalmos and conjunctival redness B: flushed, moist skin C: decreased body temp and cold intolerance D: systolic murmur at the left sternal border
C Hypothyroidism markedly decreases the metabolic rate, causing a reduced body temperature and cold intolerance. Other signs and symptoms include dyspnea, hypoventilation, bradycardia, hypotension, anorexia, constipation, decreased intellectual function, and depression. Exophthalmos; conjunctival redness; flushed, warm, moist skin; and a systolic murmur at the left sternal border are typical findings in a client with hyperthyroidism.
A nurse is preparing to administer a unit of blood to a client with anemia. After removal of the blood from the refrigerator, the transfusion of the blood must be completed within: A: 1 hr B: 2 hrs C: 4 hrs D: 6 hrs
C Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, the transfusion must be completed within 4 hours. The transfusion does not have to be completed faster than this (e.g., within 1 or 2 hours). It can proceed more quickly if the client can tolerate it, but fluid overload is a risk. The risk of contamination and bacterial growth increases unacceptably when blood is not refrigerated for more than 4 hours, so 6 hours is too long.
The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse? A: "The child's activity level is the best indicator of pain." B: "A child who resumes usual play is not experiencing pain." C: "Some children distract themselves with play while in pain." D: "Children don't experience as much pain after surgery as adults."
C Some children distract themselves with play or music while in pain and may sleep as a result of exhaustion. Nurses commonly underestimate children's pain when they do not rely on children's self-reports. Narcotics can be used safely with children.
After administering an I.M. injection, a nurse should A: recap the needle and discard the needle and syringe in any medical waste container. B: recap the needle and discard the needle and syringe in a puncture-proof container. C: discard the uncapped needle and syringe in a puncture-proof container. D: break the needle using the facility-approved device and discard the needle and syringe in any medical waste container.
C The appropriate procedure is to discard uncapped needles in a puncture-proof, leak-proof container. To reduce the risk of accidental needle sticks, the nurse should never recap a needle. The nurse should never place a used needle in a garbage can or in a medical waste container that isn't puncture-proof and leak-proof. The nurse should never break or bend a needle before discarding it. Doing so increases the risk of a needle stick.
A nurse is assessing a 6-month-old infant at a well-baby check. The parent says that the infant has been having diarrhea for the last 2 days. Which is the nurse's priority action? A: Complete designated teaching for the 6-month visit. B: Notify the HCP C: Collect more data from parent about the diarrhea. D: Instruct mother to bring the infant to the emergency department.
C The nurse should obtain a more detailed history and assessment on the infant to determine the next steps in care. Routine teaching, use of the emergency department, or notifying the primary healthcare provider is not a priority until the diarrhea is evaluated.
In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene? A: telling the client's husband that he must leave at once B: remaining with the client and staying calm C: calling a security guard and another staff member for assistance D: determining why the husband feels so angry
C The nurse who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, nurse should inform the spouse what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the nurse is in control and may defuse the situation until the security guard arrives. Telling the spouse to leave would probably be ineffective in the agitated and irrational state. Exploring the spouse's anger doesn't take precedence over safeguarding the client and staff.
Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele? A: Apply thin layers of tincture of benzoin around the defect. B: Position the neonate on the side. C: Cover the defect with moist, sterile saline dressings. D: Leave the defect exposed to air.
C The sac is kept moist by covering it with nonadherent, sterile saline dressings. The dressings will need to be moistened often to prevent them from drying out. The sac also is inspected carefully for leaks, abrasions, and signs of infection. Tincture of benzoin is an adherent and should not be used, because it could potentially cause disruption of the neonate's skin integrity. The neonate should be positioned on the abdomen to avoid tearing the sac. The sac must be kept moist. If left open to the air, it would dry out, possibly causing the sac to tear, which would allow cerebrospinal fluid to leak.
A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: A: applying bandages to cover any wounds surgical team members have B: preoperative cleansing of jewelry worn by the surgical team. C: performing a preoperative surgical scrub for at least 3 to 5 minutes. D: using sterile surgical scrubs.
C The surgical team should perform a surgical scrub lasting at least 3 to 5 minutes before any operative procedure. Although surgical gowns may be considered sterile, surgical scrubs are considered clean rather than sterile. Jewelry harbors bacteria; team members should remove it rather than simply clean it. A surgical team member with an open wound shouldn't be involved in a procedure requiring asepsis.
A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? A: Administer an antiemetic to reduce the nausea, and send the client to physiotherapy. B: Notify the dietician to change the diet to clear fluids and cancel physiotherapy until the client's strength resumes. C: Ask the dietician to visit regarding food preferences and recommend that the physician order sleeping pills. D: Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.
D Gathering information regarding possible causes of nausea helps identify changes and factors that relate to the changes. Modifying the schedule helps. Although administering an antiemetic may be beneficial, movement and activity immediately afterward will not be helpful, because the medication has not yet taken effect. Diet is not the issue, so the diet-related choice is not correct. Nausea and weakness are not an emergency and do not require immediate notification of the health care provider.
A nurse is caring for an adolescent who is in the hospital for a long-term illness. Which of the following interventions would promote the development of the hospitalized adolescent? A: Arrange for a tutor to cover missed schoolwork B: Provide the teen structure in daily activities C: Encourage the family to have fun game night activities once a week D: Connect the teen to their peer group as much as possible
D Peer visitation gives the adolescent an opportunity to continue along the path toward independence and identity. Structured daily activities would benefit the younger child, not the teenager's development. Tutoring may help maintain a positive self-image relative to schoolwork but does not have an impact on adolescent development.
