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Fundal massage steps

1. Ask the client to lie on her back with knees flexed 2. Place hand above symphisis pubis 3. Position a hand around the top of the fundus 4. Rotate upper hand to massage the uterus 5. Use slight downward pressure to compress the fundus

A nurse is admitting a client who has measles. The client should be placed in which kind of isolation? A. Airborne B. Contact C. Droplet D. Protective environment

Answer: A. Airborne

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen dressing by pulling tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves

Answer: A. Don clean gloves to remove the old dressing

A nurse is performing an admission assessment of a preschooler in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? A. Fever unresponsive to antipyretics B. Pain in weight-bearing joints C. Decreased heart rate D. Peeling of the soles of the feet

Answer: A. Fever unresponsive to antipyretics

A nurse is performing a physical assessment on a 6 month old infant. Which of the following reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro

Answer: B. Babinski

A nurse is monitoring the blood pressure of an older adult client. The nurse should understand that which of the following age-related changes can contribute to an increase in systolic blood pressure among older adults? A. Decreased cardiac output B. Decreased elasticity of the blood vessels C. Fewer nephrons in the kidneys D. Thickening of the valves

Answer: B. Decreased elasticity of the blood vessels

A nurse is reviewing the lab values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine supply

Answer: B. Preterm labor

A nurse is assessing a client who is receiving IV gentamicin 3 times daily. Which of the following findings indicates that the client is experiencing an adverse reaction? A. Hypoglycemia B. Proteinuria C. Nasal congestion D. Visual disturbances

Answer: B. proteinuria

A nurse is assessing a patient taking propanolol. Which of the following findings should indicate to the nurse that the patient is having an adverse reaction? A. Weight loss B. Wheezing C. Blood pressure 146/92 D. Heart rate 110bpm

Answer: B. wheezing

A nurse is teaching a client with a new diagnosis of peptic ulcer disease with a prescription for bismuth subsalicylate. The client asks the nurse "How will this medication help my ulcer?" What should the nurse respond? A. "This medication will decrease prostaglandins" B. "The amount of bicarbonate in the body will be increased" C. "This medication can decrease bacteria in the gastrointestinal tract" D. "This medication acts by increasing blood flow to the stomach"

Answer: C. "This medication can decrease bacteria in the gastrointestinal tract"

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse assess for? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

Answer: C. Baker's yeast

A nurse is reviewing the medical record of an older adult. For which of the following medications should the nurse conduct a hearing assessment? A. Omeprazole B. Ferrous sulfate C. Digoxin D. Furosemide

Answer: Furosemide


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