3302 Final Exam Practice Questions
A pt who is admitted for HHNS, the nurse's priority is to: 1. establish fluid replacement 2. administer oxygen 3. administer sodium bicarb 4. provide a high carb diet
1
The nurse is caring for a pt with a serum K+ of 6.2. Which dx would the nurse expect would cause this finding? 1. acute renal failure 2. malabsorption syndrome 3. NG suction 4. excessive laxative use
1
The pt is suffering from DKA, which symptoms would the nurse expect on assessment? 1. Kussamaul respirations and fruity smelling breath 2. shallow respirations and abdominal pain 3. respirations 12 and increased urine output 4. foul smelling urine
1
Which patient would be most likely to develop hyperkalemia? 1. a client with renal failure 2. a client with cirrhosis 3. a client with NG suction 4. a client with diarrhea for the last 2 days
1
What are the nursing interventions for sickle cell crisis? select all 1. hydration 2. pain relief 3. oxygen 4. hydroxyurea 5. kayexolate enema
1,2,3, 4
A patient is in labor. What risk factors will put her at risk for a postpartum hemorrhage. select all that apply 1. macrosomia 2. polyhydramnios 3. precipitous delivery 4. retained placenta 5. administration of pitocin after delivery 20 units in 1000 ml 6. breastfeeding after delivery
1,2,3,4
the 8yo pt is admitted with a dx of DKA. T 102, P 112, R 28, blood sugars 307, urine spec gravity 1.035 with ketones. ABG : pH 7.28; pCO2 36; HCO3 17; K+ 5.6. Priority nursing interventions select all 1. initiate a fluid bolus (dilution is the solution to the pollution) 2. administer insulin 3. monitor blood glucose closely 4. administer K+ supplements before giving the IV bolus 5. administer antipyretics
1,2,3,5
the nurse is anticipating caring for a pt with hypomagnesemia. She knows the following statements are true about this condition. select all 1. chronic alcoholism is a frequent cause of hypomagnesemia 2. malnutrition is frequently a cause of hypomagnesemia 3. hypomagnesemia frequently occurs with other deficiencies including hypokalemia and hypocalcemia 4. the pt on proton pump inhibitors and diuretics are at risk for hypermagnesemia 5. clinical manifestations are anorexia, n/v, lethargy, weakness, personality change, tetany 6. severe hypomagnesemia may cause generalized tonic-clonic seizures, especially in children
1,2,3,5,6
After bilateral breast cancer excisions, a 79 yo pt develops dyspnea on exertion and on examination, the nurse notes rales, expiratory wheezing, and bilateral pedal edema +3. her chest x-ray indicated mild pulmonary edema. The lab value associated with CHF is the BNP. her results are 1252. the nurse understands that this indicates...select all 1. BNP is released in response to ventricular stretch 2. a high BNP is a marker for CHF 3. a BNP > 100 means that HF is unlikely 4. BNP promotes the loss of sodium and water at the kidneys in the urine, inhibits renin release, and inhibits the secretion of ADH and aldosterone 5. by inducing blood vessels to dilate and water to be excreted in the urine, ANP and BNP reduce both blood volume and BP 6. BNP levels also help with the prognosis. if tx for HF doesn't rapidly return BNP levels to normal, the pt has a significantly higher risk of death in the months ahead
1,2,4,5,6
the pt has hyperkalemia related to tissue trauma. The serum K+ is 6.1. the nurse will implement the following interventions to treat the pt safe. select all 1. the main cause of death from hyperkalemia is cardiac dysrhytmias, so the nurse should place this pt on telemetry 2. the nurse should hold all potassium supplements including IV and oral 3. the nurse should administer diuretics such as spironolactone to reduce K+ 4. the nurse should administer kaexalate oral solution or enemas as a first and priority treatment 5. the nurse should administer insulin and glucose IV to decrease a high serum K+ if ordered 6. the nurse should be aware that pt with a critically high K+ may need dialysis
1,2,5,6
The nurse is caring for a 12hr old, 8lb newborn male. During the assessment the nurse identifies normal findings. Please select below expected findings in this baby. 1. weight is normal 2500-4000 grams 2. large blue spot over buttocks, blanches with touch 3. ears at the level just below the eye 4. chest circumference is 34. head circumference is 32 5. temp is 96.4 axillary 6. pulse is 158 7. respiratory rate 22 8. mild jaundice on the face
1,2,6
A G4P3 patient who has had 3 c/sec is pregnant for the 4th time. What are the increased risks for this patient? Select all that apply 1. placenta previa 2. placental insufficiency 3. uterine rupture 4. placenta acreta 5. severe anemia
1,3,4
The nurse is caring for 4 neonates in the nursery. The neonatalogist is asking if there are any babies at risk that he should see. Select from below which babies you think the MD should check. Select all 1. a newborn with a large bruise, cephalohematoma and a high pitched cry 2. a baby who is 6 hours old and has not voided or stooled yet 3. a neonate that has temp of 96.8 degrees and has a blood sugar of 34 4. a neonate that is mildly jaundiced with a coombs test 4+ and is 16 hours old
1,3,4
The nurse is working with a population ages 12-18 years, both male and female. In teaching this group about HPV select from the below topics that are true and should be included. 1. females should get the HPV series of vaccines at ages 9-26 years of age 2. males do not require the vaccine 3. HPV is the leading cause of throat cancer 4. HPV can cause cervical cancer 5. HPV is normal flora in most humans 6. HPV can be treated with pennicillin
1,3,4
the pt is admited with dehydration due to a fever and nausea from an infection. Select all related symptoms and nursing interventions that occur with hypovolemia A. urine specific gravity 1.031 B. urine specific gravity 1.020 C. when possible, replace fluids orally D. the nurse should administer tylenol as ordered to reduce the fever E. the nurse should monitor the pt's pulse, RR, and urine output
1,3,4,5
The pt is a post menopausal woman with a low vitamin D level and low serum calcium. She states she does not eat any dairy products or take calcium supplements. She recently broke her ankle and has been inactive. She complains of leg cramps, tingling of the nose and lips. Select from below the correct assessments and interventions 1. instruct the pt on how to increase vitamin D by sun exposure, diet and supplements 2. assess for Chovstek's sign my inflating a bp cuff and watching for palmar flexion 3. assess for heart rate and rhythm and place the pt on telemetry 4. teach the pt to avoid sunlight and to move slowly to avoid bone fractures 5. teach the pt to eat a high calcium diet and do weight bearing exercise 6. institute seizure precautions
1,3,5,6
The pt is having an amniocentesis and will be monitored on your unit afterward. Select correct teachings 1. the mom will need rhogam because she is Rh negative 2. all answers are correct 3. the pt will need fetal monitoring after the procedure 4. all mothers who are at 38 weeks gestation or greater require an amniocentesis to test for fetal lung maturity 5. the amniocentesis puts you at a slight risk for infection and maternal temperature should be monitored. The mother should notify her doctor if her temp is elevated 6. the pt should report any vaginal bleeding or cramping
1,3,5,6
The pt is dx with toxoplasmosis in her pregnancy. select from below the correct information about this infection during pregnancy 1. it may cause severe birth defects including eye and brain damage 2. it can be treated with pennicillin 3. it may cause Hutchington teeth 4. it is caused by a parasite 5. it can be prevented by avoiding cat poop
1,4,5
the nurse is working with a nursing assistant taking care of several pts. Which task may be delegated to an unlicensed person regarding a pt with a blood transfusion. select all 1. taking vital signs after the first 15 min 2. identifying the blood as a second person if a RN is not available 3. evaluating if the pt is having any adverse effects 4. checking the IV site for infiltration 5. measuring urine output
1,5
The nurse is caring for a pt with a 1200mL blood loss after surgery. The pt has a HGB of 7.2. What assessment parameters will determine if the pt needs a blood transfusion. Name 3
1. activity intolerance 2. hypotension (symptomatic) 3. someone who does not have the ability to make RBCs very easily
A client has a calcium level of 14 mg/dL. Which intervention is the priority? 1. push fluids 2. place on a cardiac monitor 3. assess for Chvostek's sign q 2 hours 4. administer IV calcium chloride
2
The client is admitted to the ER with chest trauma from a motor vehicle accident. The client has shallow respirations of 12 and states it hurts to breathe. The nurse would anticipate which ABG values from inadequate ventilation? 1. pH 7.43; PaCo2 41; HCO3 23; SaO2 96% 2. pH 7.31; PaCo2 49; HCO3 24; SaO2 87% 3. pH 7.49; PaCo2 34; HCO3 30; SaO2 89% 4. pH 7.38; PaCo2 34; HCO3 22; SaO2 90%
2
The client with hypokalemia must be assessed for which complication? 1. perforated bowel 2. paralytic ileus 3. renal failure 4. diabetes
2
The nurse assess a patient with Type 1 diabetes mellitus is at risk for which of the following acid base imbalances? 1. metabolic alkalosis 2. respiratory acidosis 3. metabolic acidosis 4. respiratory alkalosis
2
The nurse is working in a diabetic clinic and explains to a patient with diabetes that type 2 hyperglycemia may cause low mag levels due to which of the following? 1. liver toxicity 2. osmotic diuresis 3. kidney failure 4. low serum somolarity
2
The urse is administering packed RBCs. The nurse should stop the transfusion immediately if which of the following symptom occurs: 1. dry mouth and thirst 2. fever and back pain 3. hypothermia and pallor 4. heart rate 89 bpm
2
the pt has a high mag level 4.2. The nurse would anticipate which therapy to decrease Mg+ levels in the body? 1. laxatives 2. diuretics 3. antacids 4. fluid restriction
2
Which of the following, if assessed in a pt, will the HCP identify as a risk factor for the development of delirium? select all 1. decreased physical activity 2. lack of sleep 3. administration of opiods 4. lack of visitors 5. hospitalization
2,3,5
The pt is to receive an infusion of albumin. Select below from all true statements about this blood product. 1. albumin increases plasma volume especially following rapid infusion and is indicated in pts with CHF 2. albumin is a blood product and the nurse must monitor the pt closely 3. the increase in blood volume resulting from an albumin infusion compensates for loss of RBCs and is indicated in pts with severe anemia 4. angiotensin-converting enzyme inhibitors should be withheld for at least 24 hrs before administering albumin because of the risk of atypical reactions, such as flushing and hypotension
2,4
Begins with complete cervical effacement and full dilation and ends with birth of baby. contractions q 2-3 minutes for 60-75 minutes - increase in the bloody show. mother feels urge to bear down; assist with pushing efforts. monitor for s/s of approaching birth
2nd stage of labor
A pt is admitted to the ER with the following findings: heart rate of 112 (thready upon palpating) 82/64 BP, 25ml/hr urinary output, and sodium level of 156. Which nursing interventions are correct for this patient? 1. restrict fluid intake and monitor daily weights 2. administer 0.9% NaCl at 250ml per hour x4 liters then reduce to 150 ml per hr 3. Administer 0.45% NaCl as ordered. Have pt drink water and eat low salt diet. 4. administer D5 0.45% NaCl and have the pt take salt tablets
3
The nurse is caring for a pt with hyperkalemia. After administering Kayexalate what is the priority nursing action? 1. monitor urine output 2. take the client's BP q hr 3. monitor bowel movements 4. watch for EKG changes especially dysrhythmias
3
Which IV solution is compatible with blood products? 1. lactated ringers 2. D5W 3. 0.9% NaCl 4. D5 and 0.45% NS
3
Which nursing intervention is a priority if K+ is 6.1? 1. obtain ABG 2. evaluate LOC 3. obtain EKG 4. measure I&O
3
The nurse is caring for a labor pt on pitocin she will monitor for the following adverse effects. Select all that apply 1. hypoglycemia 2. hypotension 3. water intoxicatioin 4. poor resting tone 5. uterine rupture 6. late decelerations
3,4,5,6
the pt is admitted with a Ca+ of 12.01. select from below the correct nursing assessments and actions 1. the nurse should expect a positive trousseau's and Chovtek's sign 2. the nurse should administer calcium supplements 3. the nurse should inquire if the pt is taking their thiazide diuretics as ordered 4. the nurse should assess the cardiac status and place the pt on telemetry 5. this pt is at risk for a DVT and should have sequential teds and leg exercises 6. this pt may have constipation and should have an abdominal assessment. Findings may include hypoactive bowel sounds, distention, and decreased peristalsis
3,4,5,6
A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV mag sulfate. Select all nursing interventions that apply in the care for the client 1. Notify the physician if respirations are less than 18/min 2. monitor maternal vital signs every 2 hrs 3. Monitor renal function and cardiac function closely 4. monitor DTRs hourly 5. Notify the physician if urinary output is less than 30 ml per hr 6. Monitor I and O's hourly 7. keep calcium gluconate on hand in case of a mag sulfate overdose
3,4,5,6,7
The baby is diagnosed with pathological jaundice. The following are true about caring for the baby with this problem. Select all 1. the baby will have a negative coombs test 2. the mother of the baby will have Rh negative blood 3. the newborn will have jaundice in the first 24 hrs of life 4. the nurse should switch the baby to formula feedings, mom should pump and dump 5. the baby will be started on phototherapy to decrease bilirubin levels in the blood
3,5
lasts from birth of baby to expulsion of placenta. Birth of placenta occurs 5-30 minutes later. examine umbilical cord for 2 arteries and 1 vein. asses to make sure placenta is intact
3rd stage of labor
A pt diagnosed with dmeentia is prescribed a medication that inhibits acetylcholinesterase. Which of the following accurately explains how this medication benefits the patient? 1. decreased levels of acetylcholine will help decrease the pt's anxiety 2. acetylcholine increases norepi activity and decreases depression 3. inhibition of acetylcholinesterase improves the pt's motor function 4. acetylcholine is needed for memory and problem solving
4
Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? 1. The vaccine is safe in clients with egg allergies 2. Breast-feeding isn't compatible with the vaccine 3. Transient arthralgia and rash are common adverse effects 4. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects
4
Which K+ level would be of concern if the patient was taking lasix? 1. 5.4 mEq/L 2. 6.2 mEq/L 3. 4.3 mEq/L 4. 3.1 mEq/L
4
order for 24 hour urine (put in order) 1. have the pt empty the bladder at the end of the test- add to bottle 2. start the collection - store on ice 3. add urine to the bottle - if missed start over 4. instruct the pt to empty her bladder
4, 2,3,1
For most normal labors, the following must occur. Put in order 1. the cervix softens and shortens - effacement 2. mild contractions begin 3. the cervix dilates 4. the mucus plug is expelled
4,2,1,3
What serum glucose level would the nurse expect to see in a pt with DKA?
>300
A 78-year-old woman is at her annual checkup with her health care provider. She seems very embarrassed about asking if it's normal to "leak" urine when coughing or laughing, especially at her age. She has given birth to five children. What is the nurse's best response to this question? A."Involuntary loss of urine or incontinence is not a normal consequence of childbirth or aging." B."As we get older, our bodies do not function as well as when we were younger." C."The unintentional loss of urine can be temporary or permanent depending on the cause." D."The most likely cause of your urine leakage is obstruction of the urethra with a kidney stone."
A
A client is admitted to the L&D suite at 36 wees' gestation. She has a hx of 3 prior c/sec and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her s/s and what is the priority action by the nurse? A. uterine rupture, call for a rapid response, establish IV access and monitor the pt closely B. potential anxiety related to labor, stay with the pt until she awakens C. placenta previa, establish IV access and notify the provider D. dystocia, establish IV access and await further orders
A
A client is at risk for increased ICP. Which of the following would be a priority? A. unequal pupil size B. decreasing systolic blood pressure C. tachycardia D. decreasing body temp
A
A client is brought to the ER having experienced blood loss due to a deep puncture wound. A 3 unit fresh-frozen plasma is ordered. The nurse determines that the reason behind this order is to: A. provide clotting factors and volume expansion B. increase hemoglobin, hematocrit, and neutrophil levels C. treat platelet dysfunction D. treat thrombocytopenia
A
A client with a head injury has been urinating copious amounts of dilute urine through the foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: A. desmopressin B. dexamethasone C. ethacrynic acid D. mannitol
A
A normal sized, full-term infant was just born a few minutes ago. After performing the initial Apgar score, which nursing intervention should the nurse perform first? A. remove the wet blankets B. stimulate the infant to cry by rubbing the soles of his feet C. apply erythromycin ointment to both eyes D. point out the newborn's ability to see and hear his parents
A
A nurse is instructing a client who is scheduled for a transurethral resection of the prostate (TURP) about his postop care. Which of the following information should the nurse include in the teaching? A. You may have a continuous sensation of needing to void even though you have a catheter B. You will be on bed rest for the first 2 days after the procedure C. You will be instructed to limit your fluid intake after the procedure D. Your urine should be clear yellow the evening after the surgery
A
A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at -3 station, membranes are intact. The nurse determines that the fetal presenting part is high in the pelvis. Which action is not advised at this time? A. artificial rupture of fetal membranes B. ambulating for more than 30 min at a time C. vaginal exams D. taking a whirlpool
A
A pt started receiving their first unit of blood at 1000. It is now 1010 and the pt is reporting itching, chills and a headache. In addition, the pt's temp is now 99.8 from 98. The next priority nursing action is: A. stop the transfusion B. notify the physician C. decrease the rate of transfusion D. reassure the pt that this is normal and will resolve in 30 min
A
A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A. seizures do not occur B. weight loss C. ankle clonus is noted D. the blood pressure decreases
A
Identify the best indicator for the pt with excessive diuretic therapy A. BUN 25, HCT 60 and a 5.5 lb weight loss in 24 hrs B. BUN 24, HCT 58, and a 5 lb weight gain in 24 hrs C. BUN decreased and HCT decreased and an 8lb weight gain in 24 hrs D. BUN decreased and HCT decreased and an 8lb weight gain in 24 hrs
A
In the ED, the pt is dx with DKA. What is the nurse's first priority for managing this condition? A. airway assessment B. fluid and electrolyte correction C. administration of insulin D. administration of IV potassium
A
Most of the genetic tests now offered in clinical practice are tests for: A. single-gene disorders B. carrier screening C. predictive values D. predispositional testing
A
On admission, a pt's blood alcohol limit is greater than 400 mg/dL. The pt reports drinking a 12 pack of beer on a daily basis. Which of the following conditions is the pt MOST at risk for? A. hypomagnesemia B. hypermagnesemia C. hyponatremia D. hypernatremia
A
On assessment of a client who is 30 minutes after delivery, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's priority action is to (select one) A. massage the fundus B. administer pitocin C. take vital signs D. straight cath
A
The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: A. Desmopressin (DDAVP, stimate) B. Dexamethasone (Decadron) C. Ethacrynic acid (Edecrin) D. Mannitol(Osmitrol)
A
The main reason for an expected increased need for iron in pregnancy is A. the mother may have physiologic anemia due to the increased need for RBC mass as well as the fetal requires about 350-400 mg of iron to grow B. The mother may suffer anemia because of poor appetite C. The fetus has an increased need for RBC which the mother must supply D. The mother may have a problem of digestion because of pica
A
The nurse administers erythromycin ointment to the baby in both eyes after delivery. The parents ask why. Which is the correct response by the nurse? A. to prevent newborn blindness B. to prevent syphillis and chalmydial infection of the eye C. to provide lubrication to the newborn eyes D. to destroy infectious exudate caused by staphylococcus that could make the baby blind E. to prevent the baby's eyelids from sticking together and to help the baby see
A
The nurse is admitting a pt with PIH and has an order to start mag sulfate 4gm bolus. select from below a contraindication to this adminstration which would warrent a call to the provider A. BUN 25 B. platelets 158,00 C. creatanine 0.6 D. proteinuria 4+
A
The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for? A. automatisms - lip smacking B. Intermittent rigidity C. sudden loss of muscle tone D. brief jerking of the extremities
A
The nurse is caring for a mother who is 4 hrs pp. the mother is complaining about a headache, blurred vision, and afterbirth cramping. Which assessments are the priority for the nurse at this time? A. DTRs and BP B. pain level and fatigue C. apical pulse and hydration D. check to see if the headache is resolved with the supine position. pain level
A
The nurse is caring for a pp mom who is breastfeeding. On day two, her nipples are sore, blistered, and cracked. Select from below the one incorrect action to address this problem? A. have the mom wash her nipples with warm soapy water after breastfeeding B. have the mom use breastmilk directly on her nipple C. assess that the baby has a proper latch D. air dry the nipples after breastfeeding
A
The nurse is caring for a pt immediately postpartum. Which of the following behaviors characterizes the PP mother in the taking in phase? A. passive and dependent B. striving for independence and sutonomy C. exhibiting readiness for learning. best time to latch D. curiosity about the baby
A
The nurse is performing an assessment on a baby with a new circumcision. Select from below an assessment that would require immediate action. A. a small drop of fresh blood is observed and there is sanguinous drainage on the 4x4 dressing B. the infant has not voided for 4 hours after the circumcision C. there is edema of the penis D. the neonate is very sleep and won't wake up for his feeding
A
The nurse providing care for the laboring woman understands that accelerations with fetal movement: A. are reassuring B. are caused by umbilical cord compression C. warrant close observation D. are caused by uteroplacental insufficiency
A
The parents are concerned that the baby is breathing irregularly and sometimes has pauses in breathing lasting 5-10 seconds followed by short rapid breathing. What is the nurse's first priority? A. explain to the parents that this is normal for newborns B. notify the provider immediately C. apply a pulse ox and monitor the baby carefully D. undress the baby and observe for 5 min
A
The patient had a head injury with a loss of consciousness. They are in the ER chatting away when suddenly the patient has a change in LOC. The patient now has a fixed dilated pupil. The nurse suspects an epidural hematoma. What is the first priority? A. call a rapid response and do vital signs q 5 min B. notify the pt's next of kin C. administer a fluid bolus and start a second IV D. notify the provider
A
The pt had a head injury with loss of consciousness. They are in the ER chatting away when suddenly the pt has a change in LOC. The pt now has a fixed dilated pupil. The nurse suspects an epidural hematoma. What is the first priority? A. call a rapid response and do vital signs q 5 min B. notify the pt's next of kin C. administer a fluid bolus and start a second IV D. notify the provider
A
The pt has an elevated blood sugar of 312 and is going to receive some regular insulin per sliding scale. Which situation below would concern the nurse as she was preparing to administer insulin? A. the pt is NPO and has K+ of 2.8 B. the pt is NPO and has K+ of 5.8 C. the pt has a BUN of 19 and diabetes type 1 D. the pt has a urine output of 319 ml for the last 8 hrs
A
The pt is admitted with hypokalemia K+ 2.9. the nurse knows the highest priority assessment for this pt A. respiratory status: lung sounds, respiratory effort, and depth/rate B. hand grasps --> muscle weakness, risk for fall C. orthostatic hypotension D. hypoactive bowel sounds --> paralytic ileus
A
The pt is diagnosed with SIADH. he presents with confusion, tremors, muscle weakness, and ataxia. these are symptoms of the following electrolyte imbalance. select one A. hyponatremia Na+ 126 B. hypernatremia Na+ 156 C. hyperkalemia K+ 6.2 D. hypokalemia K+ 3.0
A
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours
A
What is the best way for neonates to decrease bilirubin levels A. feed early and often B. feed q 4 hours C. instruct the parents to wash the baby frequently D. administer an enema
A
Which newborn should be seen first? A. a baby that is grunting and has intercostal retractions B. a baby who is 18 hours old that has not stooled C. a breastfed baby that is too sleep to feed and has not eaten in 3 hours D. a ten pound baby that wants to breastfeed continuously and mom is getting sore nipples
A
Which of the following assessment findings would indicate to the nurse that the fluid volume excess has not been resolved? A. S3 heart sounds and moist lung crackles B. return of coherent conversation and behavior C. Urine output is increasing, specific gravity decreasing D. skin tenting decreasing
A
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. a client with a brain injury B. a client with a herniated disc C. a client with a high cervical spine injury D. a client with a stroke
A
Which symptom requires immediate intervention during a hypoglycemic episode? A. confusion B. hunger C. headache D. tachycardia
A
the client is admitted with metabolic acidosis. Which nursing assessment takes priority for this pt? A. cardiac monitoring B. risk to fall C. temp D. diet hx for the last 24 hrs
A
the nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? A. a patient receiving D5W at 125ml/hr who is NPO B. a CHF pt on digoxin and lasix C. a pt with a draining wound on IV 0.9% normal saline at 150ml per hour D. a pp mom with an EBL of 350ml on an IV of LR with 10 units of pitocin at 125ml/hr
A
the pt has 0.9% sodium chloride IV running at 125ml/hr for two days. a new order comes in to add 20 mEq of KCL to the next IV bag. What assessment finding listed below would require the nurse to notify the doctor before hanging the new IV with KCL? A. oliguria B. headache C. hypokalemia D. loose stools
A
the pt is admitted to the ICU for DKA management. The pt is receiving regular insulin with frequent finger sticks to check his glucose level. His potassium level is 2.5 and IV potassium supplements have been ordered. What assessment must be made before giving the IV potassium? A. production of at least 30 ml/hr of urine B. level of consciousness and orientation C. finger stick glucose of less than 200 D. respiratory rate of less than 24/min
A
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia Decreasing body temperature
A (?)
The HCP is teaching a pt who is dx with genital herpes about the disease. Which of the following will be included in the teaching plan for this patient? A. there is no cure for genital herpes but outbreaks can be shortened with medication B. this infection also increases your risk of HIV infection C. use condoms between outbreaks to reduce the risk of transmission D. You will not be contagious when you are taking your antiviral medications E. your infection is caused by a corkscrew bacteria called a spirochete F. Transmission of the virus can occur even if there are no visible herpes sores
A, B, C, F
A G1P0 pt has a SROM while ambulating in her room. What are the nurses priorities? A. Take temp B. perform vag exam C. assess fetal heart tones D. order a scalp PH E. attach a fetal scalp electrode F. admin antibiotics
A,B,C
select from below risk factors for neonatal respiratory distress A. meconium stained amniotic fluid B. precipitous delivery C. c/sec D. oral suctioning
A,B,C
Before going home, the patient asks what can be done to fix her problem with urine leaking. Which teaching points should the nurse be sure to include? (Select all that apply.) A. First, keep a diary of episodes of incontinence. B. Pay attention to timing and circumstances of episodes C. Kegel exercises can help strengthen the muscles that prevent urine leakage. D. You may want to avoid caffeine and other bladder irritants. E. Be sure to drink less than 2 L of fluids every day, especially in the evening.
A,B,C,D
DKA prevention A. check blood glucose levels every 4-6 hours if anorexia, nausea, or vomiting is experienced. B. check urine ketones when blood glucose is greater than 300 mg/gL C. decrease fluid intake when nausea and vomiting occur D. watch for and report any illness lasting more than 1 to 2 days E. monitor glucose whenever the pt is ill
A,B,D,E
signs of mag sulfate toxicity - select all A. absent reflexes B. respiratory rate 6 C. Flushing of the skin D. thirst E. SpO2 < 95%
A,B,E
A nurse is performing an admission assessment of a client who is scheduled for a repeat cesarean delivery for breech presentation. Which assessment finding would indicate a need to contact the physician before surgery? A. fetal heart rate of 198 B. rupture of fetal membranes C. hemoglobin 12.2; hematocrit 38 D. the presenece of 2+ pitting edema of the lower legs E. a maternal temp of 101.2 F. the pt reports eating breakfast 2 hours ago
A,B,E,F
The nurse is caring for a pt with a high fever and the dx is polynephritis. The nurse will implement all of the following interventions to promote healing. Select all A. administer an antipyretic such as tylenol B. restrict fluids C. administer antibiotics D. teach pts how to avoid UTIs E. administer pain medication
A,C,D,E
the nurse is caring for a pt with blood sugar of 1256. the pt is a newly diagnosed type 2 diabetic. which of the following symptoms is NOT a typical finding of HHNS? A. blood ph < 7.35 B. dehydration C. ketones in the urine D. osmotic diuresis E. sudden onset
A,C,E
The newborn is having respiratory distress, pulse ox- 94% on 40% oxygen, RR-82 AP-166 T 98 . Select from below correct nursing actions for this baby. Select all A. provide humidified oxygen B. position baby in trendelenberg position C. use care with oral feedings D. keep NPO
A,D
A nurse is providing discharge instructions to a client who is postop form a TURP. Which of the following instructions should the nurse include? A. avoid sexual intercourse for 3 months after the surgery B. If urine appears bloody, stop activity and rest C. Avoid drinking caffeinated beverages D. Take a stool softener once a day E. Treat pain with ibuprofen (motrin0
A,D,E
A 23 yo client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears & nose. Which of the following nursing interventions should be done first? A. position the client flat in bed and place a 4x4 in the ear B. check the fluid for dextrose with a dipstick and collect a specimen on a 4x4 C. suction the nose to maintain airwaypatency D. insert nasal and ear packing with sterile gauze 4x4
B
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A. Position the client flat in bed and place a 4x4 in the ear. B. Check the fluid for dextrose with a dipstick and collect a specimen on a 4x4 C. Suction the nose to maintain airway patency D. Insert nasal and ear packing with sterile gauze 4x4
B
A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client's plan of care to relieve the confusion? A. turn the IV rate to 50 ml per hour B. administer lasix as ordered C. place the patient in a supine position with the legs elevated D. measure I&O
B
A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer? A. atropine B. lorazepam C. phenytoin D. morphine sulfate
B
A client with group O blood type whose husband has group AB has just given birth. The major sign of ABO incompatibility in the neonate is which complication or test result? A. negative coombs test B. jaundice in the first 24 hrs C. jaundice after 27 hours D. positive rhogam test
B
A mother calls the student nurse to the bedside. She opens the babies diaper revealing greenish tar like stool. It is sticking to everything and is hard to clean. Which nursing intervention is the best action for the student nurse to perform? A. go report this to the nursing instructor and have her evaluate this thick greenish stool. B. reassure the mom that this is meconium stool and help her change the diaper C. measure the abdomen and listen to bowel sounds. Report this to the RN D. check to see if the baby has an enema order and administer it to thin this thick tar like stool
B
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. A fetal heart rate of 90 beats per minute C. Adequate resting tone of the uterus palpated between contractions D. Increased urinary output
B
A nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse's priority action? A. restrain the client's extremeties B. turn the client's head to the side C. take the client's blood pressure D. place an airway into the client's mouth
B
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? A. early decelerations B. variable decelerations C. late decelerations D. tachycardia
B
A pt at 35 weeks gestation has urine +4 protein, trace glucose, trace RBC. interpret most likely situation A. urinary tract infection, call for a C&S B. high BP - check BP and reflexes C. kidney infection - call for antibiotic D. normal values - record
B
A pt undergoing tx for HHNS has a blood glucose of 799. The doctor has ordered IV fluids and IV insulin therapy. Which of the following findings causes concern before starting insulin therapy? A. regular insulin cannot be given intravenously; therefore, the nurse needs to clarify the doctor's order B. the pt's K+ level is 3.1 C. The pt is complaining of severe thirst and has dry mucous membranes D. the pt is confused and drowsy
B
A pt with hypovolemic hyponatremia is started on IV fluids. Which of the following fluids do you expect this pt might be started on? A. 0.45% saline B. 3% saline C. D5W D. D10W
B
A wife of a pt who as undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? A. The bladder irrigation is needed to stop the postop bleeding in the bladder B. The irrigation is needed to keep the catheter from being occluded by blood clots C. normal production of urine is maintained with the irrigations until healing occurs D. antibiotics are being administered into the bladder with the irrigation solution
B
A woman delivered a 9-lb, 14-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? A. perform a bladder scan B. assess the fundus for firmness and position C. assess the perineum for lacerations D. notify the physician
B
An elderly female client with an indwelling urinary catheter is exhibiting confusion and is suspected of having a UTI. The nurse should collect a urine specimen for culture & sensitivity by: A. d/c the tubing from the urinary catheter and letting the urine flow into a sterile container B. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle C. draining urine form the drainage bag into a sterile container D. Clamping the tubing for 60 min and inserting a sterile needle into the tubing above the clamp to aspirate the needle
B
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 placenta is present. Based on these findings, the nurse would prepare the client for: A. blood transfusion and amniotransfusion B. stat c/sec C. weekly coagulation studies and LFT D. strict bedrest and general diet
B
Group B streptococci (GBS) are part of the normal vaginal flora in 20% to 30% of healthy pregnant women. GBS has been associated with poor pregnancy outcomes and is an important factor in neonatal morbidity and mortality. Risk factors for neonatal GBS infection include all except: A. positive prenatal culture B. preterm birth less than 37 weeks C. maternal fever of 38C or greater D. artificial rupture of membranes one hour before birth
B
The nurse asks why the pt is breathing so rapidly and deeply (DKA). What is the nurse's best response? A. His serum pH is high and this is a compensatory mechanism B. his serum pH is low and this is a compensatory mechanism C. his serum potassium is high and this is a compensatory mechanism D. his serum potassium is low and this is a compensatory mechanism
B
The nurse is caring for a 10lb newborn baby who is an infant of a diabetic mother, is 3 hrs old and has a blood sugar of 52. What is the correct interpretation by the nurse? A. this is an abnormally low blood sugar, call the provider and prepare to start a dextrose infusion B. this is an acceptable glucose level, feed the baby frequently and reassure the mother C. this blood sugar is abnormally low, start feeding q 2hrs and check the blood sugar q1h D. this is an abnormally high blood sugar, contract the provider and prepare for an insulin drip
B
The nurse is caring for a client with severe blood loss who is prescribed transfusion with multiple units of blood. The nurse obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias? A. cardiac monitor B. blood warmer C. ECG machine D. electronic BP machine
B
The nurse is caring for a patient who had 6 children. She is breastfeeding and complaining about after birth cramping. The nurse assesses the pain at 4-5 on a ten scale. The choices are ibuprofen, tylenol and codiene. Which medication should the nurse administer and why. Select the correct response. A. none, the nurse should get an order for morphine which may be given IV for quick pain relief. B. ibuprofen because it is an NSAID and will be more effective on cramping because of prostaglandin inhibition c. tylenol because the pain level is mild and the pt is able to take oral analgesics. D. codeine because the pain level is severe and the patient can take oral analgesics
B
The nurse is caring for pp mother who delivered by c/sec. Which of the following nursing interventions would be most important for the nurse to carry out to achieve the patient care goal: the client will not develop pp thrombophlebitis? A. promote increase oral fluid intake B. assist the pt with early ambulation C. massage her legs twice daily D. instruct the pt not to cross her legs while sitting
B
The nurse is working in a diabetic clinic and explains to a pt with diabetes that type 2 hyperglycemia may cause low mag levels due to the following A. liver toxicity B. osmotic diuresis C. kidney failure D. low serum osmolarity
B
The nurse notices the patient has distended neck veins. What is the priority assessment? A. measure urinary output and urine specific gravity B. Take BP and AP C. check DTRs D. document in the chart and continue to monitor
B
The patient presents with raccoon eyes, battle sign, bleeding in the inner ear and clear fluid draining from the nose. The diagnosis is Basilar skull fracture. The top priority for preventing further injury means the nurse will: A. Prepare the patient for the OR B. Proceed as there is a co-existing C-spine injury C. Culture the clear fluid D. Pack the nose with 4x4s
B
The patient says that a friend mentioned taking antidepressant drugs when she had a similar problem, and asks if this could help herself. What is the nurse's best response? A. "Estrogen may be helpful because it can improve vaginal and urethral blood flow." B. "Tricyclic antidepressants such as imipramine have been helpful in relieving urinary incontinence." C. "An antispasmodic drug such as oxybutynin would probably be better." D. "Your problem may be different from your friend's, requiring a different solution."
B
The pt is having a transfusion reaction. You immediately stop the transfusion. The next priority intervention is A. notify the physician B. d/c the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9% C. collect urine sample D. send the blood tubing and bag back to the blood bank
B
The pt presents with raccoon eyes, battle sign, bleeding in the inner ear and clear fluid draining from the nose. The dx is basilar skull fracture. The top priority for preventing further injury means the nurse will: A. prepare the pt for the OR B. proceed as there is a co-existing spinal injury C. culture the clear fluid D. pack the nose with 4x4s
B
The viral STI that affects most people in the United States today is: A. herpes simplex virus type 2 B. human papillomavirus C. Human immunodeficiency virus D. cytomegalovirus
B
When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A. stop the oxytocin infusion B. change the client's position C. Prepare for immediate delivery D. take the client's blood pressure
B
Which patient is at greatest risk of developing a kidney stone? A. African-American female with family history of kidney stones B. Overweight Caucasian male C. Female with history of frequent urinary tract infections D. Hispanic/Latino female who eats animal protein at every meal
B
a nurse is caring for a postop client with the following ABGs. pH 7.29; PCO2 61; PO2 81; bicarb 24; O2 sat 96. Which of these actions by the nurse is indicated? A. apply oxygen 100% using a non-rebreather mask B. encourage the pt to take deep breaths using the spirometer C. administer sodium bicarb using the standing recovery orders D. continue to monitor the pt
B
a nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? A. type 2 diabetic complaining of thirst B. a pt who received 3 units of packed RBC in the last 24 hrs C. a pt with bowel obstruction and an NG tube D. a CHF patient with 1/2lb weight gain in 2 weeks
B
a primigravida is receiving mag sulfate for the tx of PIH. the nurse who is caring for the client is performing assessments every 30 min. Which assessment finding would be of most concern to the nurse? A. DTRs 3+ B. RR of 11 C. urinary output of 25ml since the last assessment D. FHR 126
B
a pt is admitted to the obstetric unit in preterm labor at 33.4 weeks' gestation. The prescriber orders a tocolytic agent. When teaching the pt about this medication, the nurse will tell her that tocolytics A. help treat the infections that cause preterm labor B. help delay delivery while glucocorticoids are given C. are used to help the fetal lungs mature D. are given until term to reduce fetal mortality
B
the nurse is caring for a client with severe blood loss who is prescribed transfusion with multiple units of blood. The nurse obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias? A. cardiac monitor B. blood warmer C. telemetry D. electronic BP machine
B
the nurse is caring for a pt at 39 weeks gestation who arrives at the birthing center with mild contractions q10 min apart lasting 30 seconds. The mother has a positive nitrazine test (turned blue), a positive fern test, positive amnisure test, mild variable decls and head is engaged at 0 station. select the correct nursing action A. discharge the pt with instructions to return when labor begins B. admit the pt to labor and delivery, monitor maternal temp and FHR C. send the pt to ultrasound stat. notify the provider D. admit to labor and delivery, notify the physician of preterm labor, keep mom on bedrest
B
the nurse is teaching a student about administering kayexalate to lower a pt's K+ level. select from below the one statement that is not true A. the pt should take their medications 3 hours before or 3 hours after this treatment B. the pt with a bowel obstruction or poor GI function may benefit from this treatment C. this medication works by binding to K+ in the intestine D. this treatment may be contraindicated in CHF
B
the pt is requesting an epidural anesthesia for active labor. The nurse knows that most common and potentially harmful maternal complication of epidural anesthesia would be: A. limited perception of bladder fullness B. maternal hypotension C. spinal headache D. increase in maternal rr
B
Explain why a urinary tract infection is a risk for pre-term labor select all A. it will not increase risk for preterm delivery B. it increases inflammation C. It will increase risk of chorioamnitis D. Increased prostaglandin action
B,C,D
1hr old infant is grunting on arrival in the neonatal nursery. The baby is pink but has nasal flaring and intercostal retractions. Which of the following should the nurse do first? A. suction the nose and the mouth with sterile suction catheter B. notify the neonatalogist C. perform a respiratory assessment D. obtain a chest x-ray E. assess the blood glucose
C
A 21-year-old male reports burning and difficulty with urination. What priority question would obtain information about the patient's chief complaint? A. "How long have you had these symptoms?" B. "Do you have low back pain?" C. "Are you sexually active?" D. "Have you had a fever in the past 24 hours?"
C
A G4P3 is admitted to the L&D suite at 36 weeks' gestation. She has a hx of C/S and complains of severe abdominal pain that started less than 1 hr earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is much better and then passes out. Which is the probable cause of her signs and symptoms? A. hysteria compounded by the flu B. placental abruption C. Uterine rupture D. dysfunctional labor
C
A client has functional urinary incontinence. Which instruction by the nurse to the client and family helps meet an expected outcome for this condition? A. you must clean around your catheter daily with soap and water B. operations to repair your bladder are available, and you can consider these C. buy slacks with elastic waistbands that are easy to pull down
C
A client is receiving a platelet transfusion. The nurse determines that the client is gaining from this therapy if the client exhibits which of the following? A. less frequent febrile episodes B. increased level of hematocrit C. less episodes of bleeding D. increased level of hemoglobin
C
A client was admitted after sustaining a closed head injury. Several hours later, the nurse assesses that the client is more lethargic and confused, is mumbling her speech, and is very difficult to arouse. What is the source of her concern? A. the client is overtired from the events of the day B. the client is oversedated C. the client's brain injury may be worsening D. the client's ICP may be decreasing
C
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis
C
A female adult client admitted with a gunshot wound to the abdomen is transferred to the ICU after an exploratory laparotomy. Which assessment finding suggests that the client is experiencing acute renal failure? A. BUN level of 22 mg/dl B. serum creatinine level of 1.2 mg/dl C. urine output of 400ml/24hr
C
A new mother is questioning if her baby is getting enough milk from her breast. The baby is 5 days old. What is the correct answer to the mother's question? A. the newborn will sleep for 6 hrs at a time B. the newborn will have two stools every 24 hrs C. the newborn will have 6-8 wet diapers per day D. the newborn will have a sunken fontanel
C
A newborn is 4 hrs after a bath has a temp of 96.4 degrees. the skin is mottled and the baby is grunting. Which test is a priority for this baby and for which complication? A. EKGs - PVC's B. glucose test - hyperglycemia C. glucose test - hypoglycemia D. PKU test for metabolic errors
C
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: A. apply an oil-based lotion to the newborn's skin to prevent drying and cracking B. assess vital signs every hour C. place eye shields over the newborn's closed eyes D. limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea
C
A nurse is assessing a pregnant client in the 3rd trimester of pregnancy who was admitted to the maternity unite with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? A. absence of abdominal pain B. a soft abdomen C. uterine tenderness/pain D. painless, bright red vaginal bleeding
C
A nurse is caring for a pt with abdominal trauma who recently received 2 units of packed red blood cells. Which lab result below demonstrates that the blood transfusion was successful A. hemoglobin level 7g/dL B. platelets 300,000 C. hemoglobin level 14g/dL D. prothrombin time 12.5 seconds
C
A nurse is providing genetic counseling for an expectant couple who already have a child with trisomy 18. The nurse should: Select one A. Tell the couple they need to have an abortion within 2 to 3 weeks B. Explain that the fetus has a 50% chance of having the disorder C. Discuss options with the couple, including amniocentesis to determine whether the fetus is affected D. Refer the couple to a psychologist for emotional support
C
A nurse prepares to administer vitamin K injection to a newborn infant. The mother asks why her newborn infant needs the injection. The best response by the nurse would be: A. newborn babies need vitamin K to develop immunity B. newborn babies need vitamin K to assist the liver with preventing jaundice C. newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding D. Newborn infants have sterile bowels, and vitamin k promotes the growth of bacteria in the bowel
C
A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30
C
A pp nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temp is 100.2. Which of the following actions would be the highest priority? A. retake the temp in 15 minutes B. call the physician C. encourage fluids to improve hydration D. administer tylenol 650mg po
C
A pt admitted with a head injury has admission vital signs of T 98.6, BP 128/68, pulse 110, respirations 26. Which of these vitals , if taken 1 hr after admission, will be of most concern to the nurse? A. BP 130/72, pulse 90, R 32 B. BP 148/78, pulse 112, R 28 C. BP 156/60, pulse 60, R 14 D. BP 110/70, pulse 120, R 30
C
A pt has a sodium level of 112. Which of the following is NOT related to this finding? A. over secretion of ADH B. low salt diet C. inadequate water intake D. hypotonic fluid infusion (overload)
C
An adult client complains of a cough, fever and vomiting for 3 days. Assessment includes dry mucous membranes and urine specific gravity 1.031. The client is also weak and dizzy. Which vital sign is the best indicator of current fluid status? A. temperature B. respiratory rate and depth C. BP and pulse sitting, lying, and standing D. pulse ox
C
During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing dx is most appropriate? A. urinary stress incontinence B. functional urinary incontinence C. urge incontinence D. reflex urinary incontinence
C
The client is receiving an intravenous infusion of 40 mEq of potassium chloride in a 1000mL solution of dextrose 0.9% saline at 150ml/hr. The client states that the area around the IV site burns. What intervention does the nurse perform first? A. slow the IV rate down it is too fast B. notify the physician C. stop the infusion D. check for a blood return and check the site every hour
C
The hormone responsible for a positive pregnancy test is: A. estrogen B. progesterone C. Human Chorionic Gonadotropin
C
The nurse aware that the following is an appropriate nursing dx for a client with renal calculi? A. ineffective tissue perfusion B. functional urinary incontinence C. risk for infection D. decreased cardiac output
C
The nurse is caring for a newborn who was just circumcised. The priority outcome for this baby in the first few hours is: A. the newborn will void within 4 hrs of circumcision B. the newborn will have a negative NIP score C. the newborn will have no active bleeding within the next 4 hours D. The newborn will have petroleum jelly applied to the penis every diaper change
C
The nurse is caring for a pt with chronic CHF who is taking lasix and becomes confused. Which potassium level does the nurse correlate with this condition? A. K+ 5.0 B. K+ 6.2 C. K+ 2.8 D. K+ 3.5
C
The nurse providing care for the laboring woman understands that accelerations with fetal movement are A. warrant close observation B. are caused by uteroplacental insufficiency C. are reassuring D. are caused by umbilical cord compression
C
The pt is 29 weeks gestation and is in active labor with rupture of membranes and a maternal fever of 102. The pt is to receive betamethazone. What does the nurse instruct the mother about this medication? A. this medication is given to prevent preterm birth and will decrease the uterine contractions B. this medication is for your maternal infection C. this medication is given to initiate lung surfactant production D. this medication is to help with the pain
C
The pt is 37 weeks pregnant with pregnancy induced hypertension. She has been running BP's 160-180/90-112. She has blurred vision and +4 reflexes with clonus. She is started on mag sulfate. The nurse will know the mag sulfate will be effective if the following outcome is seen. A. reflexes are reduced to 0 B. fetal heart tones are showing small variable decels C. no seizures occur D. lowering of the maternal bp to WNL
C
The pt is positive for herpes simplex virus and has an active lesion. She is scheduled for a c/sec tomorrow morning for her membranes rupture with clear fluid and she is having some back cramping and states pain 4/10. What critical thinking is behind notifying the provider? A. the pt will be started on antiviral medications B. antibiotics will need to be administered promptly C. the pt will require an immediate c/sec D. the pt can have an epidural for pain
C
When should a pt with type 1 diabetes avoid exercise? A. when serum glucose is less than 150 B. during colder months C. when ketones are present in the urine D. when emotional stressors are high for the pt
C
Which of the following pts is MOST LIKELY experiencing HHNS based on their symptoms? A. a 72 yo with a health hx of diabetes who has a blood glucose of 300mg/dL and is complaining of thirst and urination B. a 66 yo with type I diabetes that has ketones present in their urine C. a 69 you admitted with an infection of the right food with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600mg/dL D. a 6yo that is presenting with polyuria, polydipsia, abdominal pain, and vomiting
C
Which of the following statements is INCORRECT about HHNS? A. HHNS occurs mainly in type 2 diabetes B. this condition presents without ketones in the urine C. metabolic alkalosis presents in severe HHNS D. IV regular insulin is used to treat hyperglycemia
C
Which of the following statements is INCORRECT about HHNS? A. HHNS occurs mainly in type 2 diabetics B. this condition presents without ketones in the urine C. metabolic alkalosis presents in severe HHNS D. IV regular insulin is used to treat hyperglycemia
C
Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12
C
Which patient below with ICP is experiencing cushing's triad? A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12
C
Which position would the nurse suggest for second stage labor if the pelvic outlet needs to be increased? A. side-lying B. semi recumbent C. squatting D. sitting
C
Your pt needs 1 unit of packed red blood cells. You've completed all the prep and the blood bank notifies you the pt's blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know that you must start transfusing the blood within A. 1hr B. 15 min C. 30 min D. 4 hrs
C
a client was admitted after sustaining a closed head injury. Several hours later, the nurse assess that the client is more lethargic and confused, is mumbling her speech, and is very diffcult to arouse. What is the source of her concern? A. the client is overtired from the events of the day B. the client is oversedated C. the client's brain injury may be worsening D. the client's ICP may be decreasing
C
a postpartum client delivered three hours ago after pushing for 2.5 hours. She just voided 100ml. The nurse palpates the fundus 3 fingerbreaths above the umbilicus and off to the right side. What should the nurse do first? A. administer ibuprofen 800mg PO B. perform a vigorous fundal massage C. insert a straight cath D. recheck the fundus in an hour
C
all of the following symptoms are true for a pt with hyponatremia except A. cerebral changes --> confusion, seizures or coma B. weakened hand grasp C. increased DTRs 3+ or 4+ may include clonus D. bowel sounds hyperactive from increased intestinal motility
C
the nurse is caring for newborn babies. To prevent heat loss in the newborn via conduction, the nurse should: A. maintain room temperature at 24C B. swaddle the newborn with a blanket and apply a cap C. pre-warm the blankets and equipment that comes into contact with the newborn D. dry the newborn immediately after bathing
C
the nurse is working on an endocrine unit. Which of the following pts is MOST LIKEY experiencing HHNS based on their symptoms? A. a 89 yo with a health hx of diabetes who has a blood glucose of 239 and is complaining of thirst and frequent urination B. a 16 yo type 1 diabetic that has ketones present in their urine C. a 76 yo admitted with an infection of the right food with a health hx of diabetes that reports missing several doses of metformin and a blood glucose of 670 D. a 6yo presenting with polyuria, polydipsia, abdominal pain, and vomitting
C
The pt phones the triage nurse from home complaining of back pain and pelvic pressure. She is 33 weeks pregnant. What is the correct response by the nurse? A. pack your bag and come in your baby is coming today B. sit down and drink 2 glasses of water, call back in a few hours if the pain continues C. come to the hospital right away to get checked D. wait until your contractions are regular and you are unable to talk during them before coming to the birthing center
C (?)
A repeat C/sec pt arrives the morning of surgery. Select from below the labs that are abnormal and state the danger. A. BUN 19 B. WBC 12,000 C. Platelets 100,000 D. H&H 98.0 and 26 E. HIV positive
C,D,E
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupil D. Decrease in LOC
D
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? A. widening pulse pressure B. decrease in the pulse rate C. dilated, fixed pupil D. decreased LOC
D
A genetic disorder in Africans which reduces oxygen uptake is: A. phenylketonuria B. hemophilia C. color blindness D. sickle cell anemia
D
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor who had a bulging bag of water that just ruptured. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the priority nursing action? A. apply warm saline compress to the cord to keep it from drying out B. run to the desk and phone the provider C. increase the rate of the IV and insert a foley catheter D. assist the mother into knee chest position and push the presenting part off the cord
D
A nurse is caring for a client in labor and is monitoring the fetal heart patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. which of the following actions is most appropriate? A. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen B. notify the physician or nurse midwife of the findings C. Reposition the mother and check the monitor for changes in the fetal tracing D. Document the findings and tell the mother that the monitor indicates fetal well-being
D
A patient undergoing a TURP returns from surgery with a 3-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The pt is complaining of painful bladder spasms. The most appropriate action by the nurse is to: A. administer the ordered IV morphine sulfate, 4mg B. Increase the flow rate of the continuous bladder irrigation C. Give the ordered belladonna and opium suppository D. manually instill 50 ml of saline and try to remove the clots
D
A postpartum woman complains to the nurse that her sleep was interrupted by sweating and the need to change her gown and bed linen. The nurses first action should be: A. assess for signs of infection B. explain that sweating is caused by her body's attempt to eliminate fluid accumulated in the pregnancy C. notify the provider D. document the finding as postpartum diaphoresis
D
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A. proteinuria of +3 B. serum mag level of 6 mEq/L C. presence of deep tendon reflexes D. respirations of 10 per minute
D
A pt is 32 weeks pregnant and arrives on the unit with painless moderate bright red vaginal bleeding. There is no uterine activity on the fetal monitor and fetal heart tones are normal. The pt did not have an ultrasound. Select below priority nursing actions & rationales. A. insert IV, type and cross for two units of blood, thought placental abruption B. insert IV, have the pt ambulate to the bathroom only, monitor for labor progress. thought bloody show C. insert IV, start running a bolus of fluids, do a speculum exam. thought preterm labor D. insert IV line, have the pt stay in bed on the monitor, monitor the pt closely, notify the provider, thought placenta previa
D
A pt is receiving 1 unit of packed RBCs. The unit of blood will be done at 1200. The pt is scheduled to have IV antibiotics at 1000 now. As the nurse you will: A. stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood transfusion B. administer the IV antibiotic via secondary tubing into the blood transfusion's y-tubing C. hold the antibiotic until the blood transfusion is done D. administer the IV antibiotic as scheduled in a second IV access site
D
A pt with a magnesium level of 4.6 would exhibit which of the following signs and symptoms except? A. hypotension B. profound lethargy C. respiratory depression D. hyperreflexia of the deep tendon muscles
D
A pt with a sodium level of 168 is ordered to be started on 0.45% saline. What is the most IMPORTANT nursing intervention for this patient? A. maintain patent IV B. give rapidly to ensure fluid levels are shifted properly C. clarify the doctor's order because 0.45% saline is contraindicated in hypernatremia D. give slowly and watch for signs and symptoms of cerebral edema
D
All statements about normal labor are true except A. a single fetus presents by vertex B. progression of contractions, effacement, dilation, and descent occurs C. no complications are involved D. it s completed within 8 hours
D
Auras are typical of A. primary GTCS B. absence seizures C. myoclonic seizures D. partial seizures
D
Later in the visit, the patient asks what could have caused her stress incontinence. What is the nurse's most accurate reply? A."It could be due to a loss of awareness that urination is about to occur." B."It most likely is related to drinking too many caffeinated beverages." C."Do you take any diuretics for your blood pressure?" D."It may be due to weakening of the bladder neck support that is associated with childbirth."
D
Methergine 0.2 mg po q 12 hours has been ordered for a G6T5P1A0L6 who is 12hrs pp because of an initial pph. The nurse should question this order if which of the following is present? A. her lochia has changed from moderate lochia rubra to scant lochia rubra B. she uses albuterol prn for mild asthma C. her pulse rate of 98 bpm D. her blood pressure is 154/88
D
RhoGAM is prescribed for a woman following delivery of a newborn infant and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following? A. developing physiological jaundice B. Having Rh positive blood C. Developing a rubella infection D. Being affected by Rh incompatibility
D
The HCP is assessing a female pt dx with trichomonias. Which of the following characteristics would the healthcare provider use to describe the vaginal discharge of this pt? A. white curdy like cottage cheese B. thin and clear C. scant and blood tinged D. frothy and malodorous
D
The most appropriate statement that the nurse can make to bereaved parents is: A. "you have an angel in heaven" B. "I understand how you must feel" C. "You're young and can have other children" D. "I'm sorry"
D
The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client? A. keep an oral airway at the bedside B. ensure fluid intake of at least 3L/day C. Teach the client pursed-lip breathing techniques D. maintain the head of the bed at 30 degrees or greater. Elevation of the back rest will help prevent aspiration
D
The nurse is caring for newborn infants. The nurse knows that the most CRITICAL physiological change required of the newborn immediately after delivery is: A. closure of fetal circulation B. full function of the immune system C. maintenance of a stable temperature D. initiation and maintenance of respirations
D
The patient was three months pregnant and had a pregnancy loss. Because the client is Rh negative, the nurse must: A. make certain the client does not receive RhoGAM, since the gestation only lasted 12 weeks B. Not give RhoGAM, since it is not used with the birth of a stillborn C. Make certain she receives RhoGAM on her first clinic visit D. Administer RhoGAM within 72 hours
D
The pt is having a quad screen for antenatal testing. The AFP is used to help determine clinical action. Select from below the one wrong statement about AFP A. low AFP may indicate risk for maternal hypertension B. low AFP is associated with trisomy 21 or down syndrome C. high AFP may indicate multiple pregnancy such as twins D. low AFP may indicate neural tube defect
D
When performing nursing care for a neonate after birth, which intervention has the highest nursing priority? A. obtain a blood glucose B administer a bath C. administer vitamin K D. apply a cap
D
When reviewing the medical record of a pt dx with alzheimer's disease, the HCP notes the pt is aphasic. Which behavior supports this finding? A. difficulty moving lower extremities B. unable to recognize objects C. difficulty swallowing D. unable to speak
D
Which client is at greatest risk for developing hypercalcemia? A. client taking furosemide for heart failure B. client with long-standing osteoarthritis C. woman who is pregnant with twins? D. client with hyperparathyroidism
D
Which of the following pts is MOST at risk for hypermagnesemia? A. a pt with alcoholism B. a pt taking a proton-pump inhibitor called protonix C. a pt suffering from Crohn's disease D. a pt receiving IV mag sulfate
D
Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, pulse 118 beats/min, respirations 33 breaths/min, and temp 98.0. What subjective data supports a dx of renal calculi? A. pain radiating to the upper right quadrant B. Hx of mild flu symptoms last week C. dark-colored coffee-ground emesis D. dark, scanty urine output
D
a client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity? a. atonic seizure b. absence seizure c. myoclonic seizure d. tonic clonic seizure
D
a nurse has assessed a woman who had a SVD 12 hrs ago. Which finding would require further assessment? A. bright red to dark uterine discharge B. midline episiotomy approximated, moderate edema, minimal bruising - ice applied C. protrusion of abdomen with slight separation of abdominal muscles D. fundus at 2/u to the right of midline
D
the nurse is caring for a client receiving a transfusion of packed RBCs. the client started to vomit and to be nauseous. Client's bp is 92/40 mmHg from a baseline of 110/70 mmHg. The client's temp is 101.5 orally from a baseline of 99.5. The nurse understands that the client may be experiencing which of the following? A. circulatory overload B. delayed transfusion reaction C. hypocalcemia D. septicemia
D
A client who is 38 weeks gestation is receiving a continuous IV infusion of mag sulfate. Which of the following findings require action by the nurse? select all A. respirations 14/min B. 3+ DTRs C. BP 150/94 mmHg D. Mag lab value of 3 mEq/L E. Urine output of 80ml in 4 hrs
D,E
What organism is the most common cause of polynephritis?
E. coli
True of False you may hang an IV piggy back to run in the same line as blood
False
A pt arrives in the ER with confusion, c/o severe headache - "it may explode" She had entered a contest to see who could drink the most water in an hour. She had 10 glasses. What type of fluid & electrolyte imbalance is present? What labs would you want to do?
Hypervolemic hyponatremia ICP, assess LOC and behavior, vital signs
Betamethasone is administered to mom's less than 37 week's gestation True False
True
First time mom's normally have longer labors than multips True False
True
dilation 4-7 cm, contractions q 3-5 min for 40-70 seconds with moderate to severe intensity. mother feeling helpless, restless, and anxious. help with breathing pattern, comfort, void q 1-2 hrs, may have an epidural at this stage. magic shower and positioning is important
active phase
A pt has a low phosphorus level. What are the symptoms that would be seen in this patient? A. changes in your mental state (for example, anxiety, irritability, or confusion) B. bone issues, such as pain, fragility, and poor development in children C. irregular breathing D. fatigue E. loss of appetite F. muscle weakness
all
A 37 weeks, G3P2 woman comes in and has +GBS and + herpes with active lesions. Her membranes ruptured at home 10 hours ago. She has a temp of 102.3, FHT's are 180-190. What is concerning here? What is the top priority? What is the analysis of the FHT's? What are 3 risks for the fetus?
all is concerning top priority: emergency c/sec, antibiotics FHT's are too high 3 risks: active herpes infection, GBS infection, hypoglycemia
Which of the following are signs of increased ICP in infants? 1. tense or bulging fontanels 2. separated sutures 3. setting-sun eyes 4. irritability 5. high-pitched cry 6. distended scalp veins 7. feeding problems 8. projectile vomiting
all true
prewarming the warmer is an example of this
conduction
wrapping the baby in a blanket and applying a hat is an example of this
convection
drying the newborn is an example of this
evaporation
True or False Hypertonic fluids, such as 3% saline, are the first line of treatment to correct dehydration in HHNS
false
True or False The pt with HHNS is to have fluids restricted during therapy
false
True or False When administering IV insulin the pt is at risk for hyperkalemia
false
True or False a newborn with persistent hypoglycemia is to be started on D10W IV. Will this baby need to be NPO?
false
true of false fresh frozen plasma is not a blood product and can be given to a Jehovah's witness
false
the nurse is caring for a pt with polynephritis what are the s/s of this condition?
fever > 102, cloudy urine, painful urination, back pain
When the baby is stable and is weaning off the IV what complication is the baby at risk for?
hypoglycemia
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: A. severe PP headache B. limited perception of bladder fullness C. increase in RR D. hypotension
hypotension
keeping the baby away from a cold window is an example of this
radiant
Pre-ictal phase
restlessness and/or altered behavior prior to start of seizure. auras
why do we hesitate to transfuse a pt?
risk for reaction, and blood borne pathogens, can't make own RBCs after
which medications may cause incontinence?
sedatives & narcotics, adrenergic agents, anticholinergic drugs, zofran
why do pts strain their urine
to check for stones
True or false you will administer platelets over 15 seconds or as fast as possible
true
true of false pt may require diuretic after receiving blood to treat fluid overload
true
true or false benadryl is often given for itching during or after a blood transfusion
true
true or false if the pt has wheezing you must stop the blood transfusion
true
