Comprehensive

A 66 year old male client attended the A & E unit complaining of cyanosis, confusion and pleuritic chest pain. Assessment revealed temperature of 37 degrees Celsius, diaphoresis and productive cough. He was admitted to the medical ward with a diagnosis of pneumonia.Which of the following statements is an appropriate nursing diagnosis for oxygen exchange and transport that should be included in the client's nursing care plan? "Alteration in breathing pattern related to muscle fatigue." "High risk for activity intolerance related to the aging process." "Alteration in gas exchange related to increase respiration as evidenced by tachypnea." "Ineffective airway clearance related to decrease functional cilia as evidenced by non-productive cough."

Correct answer "Alteration in gas exchange related to increase respiration as evidenced by tachypnea."

After instructing a primigravid client about desired with gain during pregnancy, the nurse determines that the teaching is has been successful when the client states which of the following? "A total weight gain of approximately 20lb (9 kg) is recommended." "A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal." "A weight gain of about 12 lb (5.5 kg) every trimester is recommended." "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

Correct answer "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

The clinic nurse instructs a client with diabetes mellitus about how to prevent diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the need for further instructions? "I need to stop my insulin if I am vomiting." "I need to eat 10 to 15g of carbohydrates ever 1 to 2 hours." "I need to call my physician if I am ill for more than 24 hours." "I need to drink small quantities of fluid every 15 to 30 minutes."

Correct answer "I need to stop my insulin if I am vomiting."

After the nurse evaluated the instructions given to a client with pulmonary embolism who is being discharged from the hospital, it was determined that additional teaching was required when the client made which of the following statements? "I will limit my daily fluid intake." "I will sit down whenever possible." "I will continue to wear supportive hose." "I will only cross my legs at the ankle and not at the knees."

Correct answer "I will limit my daily fluid intake."

A primigravid client at 16 weeks gestation has had an amniocentasis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? "I need to call if I start to leak fluid from my vagina." "If I start bleeding, I will need to call back." "If my baby does not move, I need to call my health care provider." "If I start running a fever, I should let the office know."

Correct answer "If my baby does not move, I need to call my health care provider."

While the nurse is performing physical examination for a multigravida in her third trimester, the client in protest states "I which I didn't have to do this every time." Which of the following would be the nurse's BEST response? "Can you tell me the purpose of these visits?" "Do you want to have a healthy pregnancy?" "We need to get baseline information for future visit." "It will help in monitoring the progress of your pregnancy."

Correct answer "It will help in monitoring the progress of your pregnancy."

The nurse is caring for a client who says "I don't want you to touch me," I'll take care of myself". Which nursing response is MOST therapeutic? "Ok if that's what you want, I'll leave this cup for you to collect your urine." "If you don't want our care, why did you come here." "Why are you being so difficult, I only want to help you." "Let's work together so you can do things yourself."

Correct answer "Let's work together so you can do things yourself."

A 39 year old multigravida client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching? "My fallopian tubes will be tied off through a small abdominal incision." "Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%." "After this procedure, I must abstain from intercourse for at least 3 weeks." "Both of my ovaries will be removed during the tubal ligation procedure."

Correct answer "My fallopian tubes will be tied off through a small abdominal incision."

A multigravida client will be using medroxyprogesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching? "This method of family planning requires monthly injections." "I should have my first injection during my menstrual cycle." "One possible adverse effect is absence of menstrual period." "This drug will be given by subcutaneous injections."

Correct answer "One possible adverse effect is absence of menstrual period."

A primigravid client at 28 weeks gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hundred miles away. Which of the following recommendations by the nurse would be best? "Try to avoid travelling anywhere in the car during your third trimester." "Limit the time you spend in the car to a maximum of 4 to 5 hours." "Taking the trip is okay if you stop every 1 to 2 hours and walk." "Avoid wearing your seat belt in the car to prevent injury to the fetus."

Correct answer "Taking the trip is okay if you stop every 1 to 2 hours and walk."

The client states "I do not want to breast feed, it's difficult." Which of the following responses by the nurse is NOT factual?" "Breastfeeding fives babies all the nutrients they need for healthy development." "Breastfeeding helps you to bond with your baby." "Breastfeeding provides an element of birth control in the first six months after birth." "That's OK, modern baby formula is almost the same as breast milk."

Correct answer "That's OK, modern baby formula is almost the same as breast milk."

A 26 year old female is concerned about her first baby who is diagnosed with hydrocephalus. The mother tells the nurse "I do not feel comfortable caring for my baby at home." Which of the following would be MOST appropriate for the nurse to make? "Do you have concerns about the care for your baby at home?" "We have good children doctors who would care for the baby at home." "What exactly makes you unhappy about your baby going home?" "As a mother you have to try and cope with your baby's condition at home."

Correct answer "What exactly makes you unhappy about your baby going home?"

A physician's orders indicate that a surgical consent needs to be signed. The nurse was not present when the surgeon discussed the surgical procedure with the client. Which statement by the nurse best illustrates fulfillment of the client's advocate role? "The doctor has asked that you sign this consent form." "Do you have any questions about the procedure?" "What were you told about the procedure you are going to have?" "Remember that you can change your mind and cancel the procedure."

Correct answer "What were you told about the procedure you are going to have?"

Which of the following is a normal fetal heart rate at 38 weeks gestation? 80 BPM 100 BPM 150 BPM 180 BPM

Correct answer 150 BPM

A client with Parkinson's disease has begun therapy with levodopa. The nurse determines that the client understands the action of the medication if the client verbalizes the results may not be apparent for: 1 week 24 hours 5 to 7 days 2 to 3 weeks

Correct answer 2 to 3 weeks

A client is 16 weeks pregnant is booked for care at the antenatal clinic. What would be her gestational age at the next routine visit? 22/40 20/40 19/40 18/40

Correct answer 20/40

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.Using the rule of nines, what is the percentage of burns sustained by the client? 27 36 45 72

Correct answer 45

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.The client weighs 50 kg. The doctor has ordered fluids at 4mls/kg/BSA % burns. How much fluid should she receive in the first eight (8) hours? 2700 3600 4500 7200

Correct answer 4500

Which of the following situations represents the BEST example of passive immunity? A 10 year old child receiving vaccination of measles. Production of antibodies in a person with an infection. A 5 month old baby receiving breast milk from the mother. A 45 year old adult receiving broad spectrum antibodies for an infection.

Correct answer A 5 month old baby receiving breast milk from the mother.

Which of client is at greatest risk for coronary artery disease? A 32 year old female with mitral valve prolapse who quit smoking 10 years ago. A 43 year old male with family history of CAD and cholesterol level of 158. A 56 year old male with an HDL of 60 who takes atorvastatin (Lipitor). A 65 year old female who is obese with an LDL of 188.

Correct answer A 65 year old female who is obese with an LDL of 188.

There are several cases of malaria on the ward. When the charge nurse speaks of the need to break the chain of infection "at the second link" she is referring to: The susceptible host. An area for the storage filtering water. A place where the microorganism enters the body. A place where the microorganism naturally lives

Correct answer A place where the microorganism naturally lives

During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when palpation of the radial pulse reveals: Two regular beats followed by one irregular beat. An irregular rhythm with pulse rate greater than 100. Pulse rate below 60 bpm. A weak, thready pulse.

Correct answer An irregular rhythm with pulse rate greater than 100

A 30 year old client is admitted to the operating theatre for surgery for an ectopic pregnancy. The anesthetic nurse receives her, conducts her assessment and completes the pre-operative checklist.The client complains of dry mouth and drowsiness after receiving some medication prior to leaving the Accident and Emergency Department for the operating theatre. This is a normal action of what category of drugs? Cholinergic Anticholinergic Beta adrenergic Alpha Adrenergic

Correct answer Anticholinergic

A 50 year old 75kg is complaining of pain after 15 minutes of being in the recovery room. The order is for Demerol 100mg IM. The BEST action of the nurse is: Delay administration of drug. Administer the drug as prescribed. Ask the doctor to review the order. Check the last time analgesics were given.

Correct answer Ask the doctor to review the order.

The nurse is performing an initial assessment for a client from a culture the nurse is not familiar with and ask about the client's use of alternative therapies. The client says irritably "Do you have to ask all these question?" Which of the following is the BEST explanation for what the nurse should do in response? Ask the question, because the nurse might learn about therapies used by a different culture. Ask the question, because knowledge about actual use of other therapies is imperative. Don't ask the question because it is important to not upset the irritable client any further. Don't ask the question, because the client needs to choose to initiate discussion of other therapies.

Correct answer Ask the question, because the nurse might learn about therapies used by a different culture.

When measuring the fundal height of a primigravid client at 20 weeks gestation, the nurse will locate the fundal height at which of the following points? Halfway between the client's symphysis pubis and umbilicus. At about the level of the client's umbilicus. Between the client's umbilicus and xiphoid process. Near the client's xiphoid process and compressing the diaphragm.

Correct answer At about the level of the client's umbilicus.

At which of the following locations would the nurse expect to palpate the fundus of a primiparous client immediately after delivery of a neonate? Halfway between the umbilicus and the symphysis pubis. At the level of the umbilicus. Just below the level of the umbilicus. Above the level of the umbilicus.

Correct answer At the level of the umbilicus.

Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is likely to be found guilty of which of the following? Unintentional tort Assault Invasion of privacy Battery

Correct answer Battery

The mechanism by which opioids work is that they: Bind to pain receptor sites in the central nervous system. Inhibits the synthesis of inflammatory mediators at the site of injury. Control anxiety, thereby reducing perception of pain. Cause sedation, thereby decreasing perception to pain.

Correct answer Bind to pain receptor sites in the central nervous system.

The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which of the following organs in the neonate? Kidneys Brain Lungs Liver

Correct answer Brain

What is the BEST source of fluids for an infant aged 3 to 12 months? Boiled tap water. Warm fruit juice. Dilute nonfat dry milk. Breast milk or formula.

Correct answer Breast milk or formula.

A 60 year old client with renal failure was educated about the necessity of having a potassium diet. The nurse identified that he needed more teaching when he stated that he could eat: Cantaloupe and pomegranate Cantaloupe and applesauce Cherries and pomegranate Applesauce and cherries

Correct answer Cantaloupe and pomegranate

When developing a teaching plan for an 18 year old client who asks about treatments for sexually transmitted diseases, the nurse should explain that Acyclovir (Zovirax) can be used to cure herpes genitalis. Chlamydia trachomatis infections are usually treated with penicillin. Ceftriaxone sodium (Rochephin) may be used to treat Neisseria gonorrhoeae infections. Metronidazole (Flagyl) is used to treat condylomata acuminate.

Correct answer Ceftriaxone sodium (Rochephin) may be used to treat Neisseria gonorrhoeae infections.

A 66 year old male client attended the A & E unit complaining of cyanosis, confusion and pleuritic chest pain. Assessment revealed temperature of 37 degrees Celsius, diaphoresis and productive cough. He was admitted to the medical ward with a diagnosis of pneumonia.Which of the following manifestations presented by the client is associated with initial manifestation of infection in the elderly? Confusion Diaphoresis Pleuritic chest pain Elevated temperature

Correct answer Confusion

While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother's temperature is (37.20 C), the pulse is 66bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should Continue to monitor the client's vital signs. Assess the client's lochia for large clots. Notify the client's physician about the findings. Offer the mother an ice pack for her forehead.

Correct answer Continue to monitor the client's vital signs.

How should the nurse help the client prepare for terminating the therapeutic relationship? Encourage autonomous activities by the client. Reassure the client that he/she will still be around. Tell the client that another nurse will take over to provide more support. Tell the client continuation is necessary, as things have improved.

Correct answer Encourage autonomous activities by the client.

A 30 year old client is admitted to the operating theatre for surgery for an ectopic pregnancy. The anesthetic nurse receives her, conducts her assessment and completes the pre-operative checklist.To prevent complication of abdominal surgery, the MOST important post-operative nursing intervention is to: Monitor vital signs. Encourage deep breathing and coughing. Check the operation site frequently. Check vaginal discharge frequently.

Correct answer Encourage deep breathing and coughing.

Twelve hours after a vaginal delivery with epidural anesthesis, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next? Document this as normal findings in the client's record. Contact the physician for a prescription for methylergonovine (Methergine). Encourage the client to ambulate to the bathroom and void. Gently massage the fundus to expel the clots.

Correct answer Encourage the client to ambulate to the bathroom and void.

The client confides in the nurse that she is afraid of not waking up after surgery. A possible nursing diagnosis for this client is: Fear related to unknown outcome of surgery. Ineffective individual coping related to surgery. Anxiety related to perceived inability to deal with possible pain. Knowledge deficit related to coping with postoperative pain.

Correct answer Fear related to unknown outcome of surgery.

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.Which of the following is the priority of car for the patient? Prevention of infection. Fluid resuscitation. Airway protection. Pain management.

Correct answer Fluid resuscitation.

Crackles heard on lung auscultation indicate which of the following? Cyanosis Bronchospasm Airway narrowing Fluid-filled alveoli

Correct answer Fluid-filled alveoli

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.Calculation of fluids for resuscitation of the patient in the first eight hours should begin: From the time of IV access. From the time of injury. Within ten minutes of the burn. Within the first hour after the burn.

Correct answer From the time of injury.

The nurse ascertains from taking a client history that she has given birth to twelve children of which six is alive, had two abortions and is currently pregnant. The nurse records the client data as: Gravida 13, para 6, plus 2 Gravida 12, para 6, plus 2 Gravida 13, para 2, plus 6 Gravida 12, para 2, plus 6

Correct answer Gravida 13, para 6, plus 2

A 30 year old client is admitted to the operating theatre for surgery for an ectopic pregnancy. The anesthetic nurse receives her, conducts her assessment and completes the pre-operative checklist.The client's risk of surgical complications is increased if she: Is dehydrated. Is underweight. Is of African descent. Has a history of taking herbal medicines.

Correct answer Has a history of taking herbal medicines.

Preoperatively, the nurse develops a plan to prepare a 7 month old infant psychologically for a scheduled herniorrhaphy the next day. Which of the following should the nurse expect to implement to accomplish this goal? Explaining the preoperative and postoperative procedures to the mother. Having the mother stay with the infant. Making sure the infant's favorite toy is available. Allowing the infant to play with surgical equipment.

Correct answer Having the mother stay with the infant.

During a postpartal visit, a client whose infant is now 4 weeks old complains of leg cramps. The nurse suspects: Hypercalcemia and tells her to increase her activity. Hypercalcemia and tells her to increase her intake of milk. Hyperkalemia and tells her to see a physician immediately. Hypokalemia and tells her to increase her intake of green leafy vegetables.

Correct answer Hyperkalemia and tells her to see a physician immediately.

A 25 year old male is brought to the emergency department suffering from multiple gunshot wounds. There is active bleeding and he is exhibiting signs of shock. The patient's vital signs are: P140, RR 32, BP 90/60. Which of the following types of shock is the patient experiencing? Distributive Cardiogenic Neurogenic Hypovolemic

Correct answer Hypovolemic

Risk factors associated with teenage pregnancy include:i. Antenatal and Perinatal complicationsii. Increased fetal and maternal morbidityiii. Post-maturity and congenital disorders I only I and II only II and III only I, II and III

Correct answer I and II only

Which of the following considered PRESUMPTIVE signs of pregnancy?I. Nausea and Vomiting.II. Urinary frequency and fatigue.III. Quickening and Softening of the cervix.IV. Ballottement and positive Hegar's Sign. I and II only I and III only II and III only II and IV only

Correct answer I and II only

An elderly is transferred to the recovery room following abdominal surgery. Which of the following interventions in the recovery room will reduce the risk of the patient becoming confused?I. Reversal of unaesthetic agentII. Maintaining adequate oxygenationIII. Maintaining fluid and electrolyte balance I and II only I and III only II and III only I, II and III

Correct answer II and III only

Which of the following topics should be included in a teaching plan for the client during the FIRST TRIMESTER of pregnancy?"I. Hospital registration.II. Danger signs in pregnancy.III. Expecting changes in pregnancy.IV. Prevention of high risk pregnancy. I and II only I and III only II and III only II and IV only

Correct answer II and III only

The postpartum nurse should encourage newly delivered clients to ambulate early in order to: Promote respiration. Increase the tone of the bladder. Maintain tone of abdominal muscles. Increase peripheral vasomotor activity.

Correct answer Increase peripheral vasomotor activity

A 66 year old male client attended the A & E unit complaining of cyanosis, confusion and pleuritic chest pain. Assessment revealed temperature of 37 degrees Celsius, diaphoresis and productive cough. He was admitted to the medical ward with a diagnosis of pneumonia.The client is coughing up thick tenacious secretions. Which of the following interventions would best liquefy these secretions? Increased intake of fluids. Administer humidified air. Percuss over the affected lung. Encourage deep-breathing exercises.

Correct answer Increased intake of fluids.

A client with angina is taking nifedipine. The nurse should teach the client to: Monitor blood pressure monthly. Perform daily weights. Inspect gums daily. Limit intake of green leafy vegetables.

Correct answer Inspect gums daily.

Which of the following nutritional requirements are MOST appropriate for the teenager mother? Calories, fibre, protein and sodium Iron, calcium, protein and vitamins Vitamins, protein and potassium Calories, sodium and fibre

Correct answer Iron, calcium, protein and vitamins

A 66 year old male client attended the A & E unit complaining of cyanosis, confusion and pleuritic chest pain. Assessment revealed temperature of 37 degrees Celsius, diaphoresis and productive cough. He was admitted to the medical ward with a diagnosis of pneumonia.The client begins to experience signs of hypoxia. Which of the following is an initial mental change that can occur? Coma Apathy Irritability Depression

Correct answer Irritability

The nurse ascertains from an initial interview that the first day of the client's last menstrual period was September 28, 2013. According to Naegele's Rule the nurse determines that the client estimated date of delivery is: May 4th 2014 July 5th 2014 July 8th 21014 August 6th 2014

Correct answer July 5th 2014

A female client who had surgical repair of the bladder is being discharged from the hospital with an indwelling urinary catheter. What statement by the client would let the nurse determine that the client understands the principles of catheter management? Cleanse the perineal area with soap and water. Keep the drainage bag lower than the bladder. Limit fluid intake so that the bag would not full so quickly. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.

Correct answer Keep the drainage bag lower than the bladder.

A 30 year old client is admitted to the operating theatre for surgery for an ectopic pregnancy. The anesthetic nurse receives her, conducts her assessment and completes the pre-operative checklist.A blood urea nitrogen or creatinine screening test is done routinely on parents before surgery to assess the functioning of the: Lungs Heart Liver Kidneys

Correct answer Kidneys

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.Which intravenous fluid would most likely be prescribed for this client? Lactated Ringer's 5% Dextrose in Water 0.9% Sodium Chloride 5% Dextrose, 0.9% Saline

Correct answer Lactated Ringer's

The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following? Left ventricular atrophy. Irregular heartbeats. Peripheral vascular occlusion. Pacemaker placement.

Correct answer Left ventricular atrophy.

An 88 year old male client was admitted to the surgical ward for management of a fractured hip. He had internal fixation of a pin. Which of the following is the reason for the pin as the treatment of choice? Is the simplest procedure. Promotes rapid healing. Carries less danger of infection. Makes earlier mobilization possible.

Correct answer Makes earlier mobilization possible.

Four hours after delivering a viable neonate by spontaneous vaginal delivery under epidural anesthesia, the client states she needs to urinate. The nurse should next: Catheterize the client to obtain an accurate measurement. Palpate the bladder to determine distention. Assess the fundus to see if it is at the midline. Measure the first two voiding and record the amount.

Correct answer Measure the first two voiding and record the amount.

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.Which analgesic is most likely to be ordered for this patient for pain management? Diclofenac Sodium Tramadol Pethidine Morphine

Correct answer Morphine

A 34 year old multiparous client at 16 weeks gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. The nurse interprets this as which of the following? The possibility that the client is carrying twins. Unusual because most multiparous clients do not experience quickening until 30 weeks gestation. Evidence that the client's estimated date of delivery is probably off by a few weeks. Normal because multiparous clients can experience quickening between 14 and 20 weeks gestation.

Correct answer Normal because multiparous clients can experience quickening between 14 and 20 weeks gestation.

The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: Observe careful handwashing procedures. Clean the incisional area with an antiseptic. Use prepackaged sterile dressings to cover the incision. Place soiled dressings in a waterproof bag before disposing of them.

Correct answer Observe careful handwashing procedures.

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of doing which of the following? Maintaining a high fiber diet. Walking 2 miles every day. Obtaining daily weights at the same time each day. Remaining sedentary for most of the day.

Correct answer Obtaining daily weights at the same time each day.

A primiparous client, 48 hours after a vaginal delivery, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following? Orange juice Herbal tea Milk Grape juice

Correct answer Orange juice

In the recovery room the MOST important client goal is achieving: Relief of pain and anxiety. Urine output of>0.5 ml/kg/hr Mean arterial pressure of 75-105mmHg PaO2 60 - 100 mmHg, PaCO2 35 - 45mmHg

Correct answer PaO2 60 - 100 mmHg, PaCO2 35 - 45mmHg

A 30 year old client is admitted to the operating theatre for surgery for an ectopic pregnancy. The anesthetic nurse receives her, conducts her assessment and completes the pre-operative checklist.The client expresses concerns about the proposed surgery site, as she loves wearing bikini on the beach. The nurse reassures her that the proposed operation site will not inhibit that action. This type of incisional site is called: Midline McBurney's Paramedion Pfannenstiel

Correct answer Pfannenstiel

A primigravid client at 36 weeks gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which of the following suggestions would be most helpful? Practice relaxation techniques before bedtime. Drink a cup of hot chocolate before bedtime. Drink a small glass of wine with dinner. Exercise for 30 minutes just before bedtime.

Correct answer Practice relaxation techniques before bedtime.

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to: Prepare the client for ambulation. Promote urinary and intestinal elimination. Prevent thrombophlebitis and blood clot formation. Decrease the likelihood of pressure ulcer formation.

Correct answer Prevent thrombophlebitis and blood clot formation.

The nurse is teaching a group of teenagers about the importance of folic acid in pregnancy. Which of the following statements would BEST indicate the benefit of the folic acid to the baby? Building the baby's blood. Maintaining healthy growth in the fetus. Promoting strong bones and teeth in the fetus Preventing defects in the baby's nervous system.

Correct answer Preventing defects in the baby's nervous system.

The first fetal movement felt by the mother is known as: Quickening Ballottement Lightening Engagement

Correct answer Quickening

A 66 year old male client attended the A & E unit complaining of cyanosis, confusion and pleuritic chest pain. Assessment revealed temperature of 37 degrees Celsius, diaphoresis and productive cough. He was admitted to the medical ward with a diagnosis of pneumonia.Which of the following is the purpose of bed rest during the acute phase of the patient's illness? Promote safety. Decreased basal metabolic rate. Promote clearance of secretions. Reduce cellular demand for oxygen.

Correct answer Reduce cellular demand for oxygen.

A nursing diagnosis of fluid volume excess was identified for a client with cirrhosis of the liver. What would the related factor be to guide nursing interventions? Localized inflammation. Increased oral intake. Renal impairment. Reduced protein.

Correct answer Reduced protein.

When teaching the parent of an infant with Hirchsprung's disease who received a temporary colostomy about the types of foods the infant will be able to eat, which of the following would the nurse recommend? High-fiber diet Low-fat diet High-residue diet Regular diet

Correct answer Regular diet

The nurse determines the need for further instruction regarding the use of incentive spirometer if the client does which of the following? Inhales slowly. Breaths through the nose. Removes the mouthpiece to exhale. Forms a tight seal around the mouthpiece.

Correct answer Removes the mouthpiece to exhale

The nurse conducts an assessment on a 45 year old woman who states that during the interview "I'm so tired all the time and have been having mood swings and hot flushes." Which of the following body systems would the nurse use to conduct a more in-depth assessment? Respiratory and nervous. Reproductive and endocrine. Nervous and cardiovascular. Cardiovascular and endocrine.

Correct answer Reproductive and endocrine.

The nurse makes a home visit to an 88 year old woman who lives alone. The assessment revealed that she has deficits in vision and hearing and is taking diuretics, which are making her crazy. Which of the following patient problem would the nurse include in her plan of care? Altered consciousness. Risk for accidental injury. Risk for impaired judgement. Decreased social interaction.

Correct answer Risk for accidental injury.

The oncologist examines a client in the clinic with severe bone marrow depression and subsequently admits him to the hospital. The client's therapy includes radiation and chemotherapy. Which of the following nursing diagnosis takes PRIORITY in the client's care plan? Imbalanced nutrition less than body requirements. Risk for infection. Pain Risk for Injury

Correct answer Risk for infection.

During a teaching session a young couple asks the nurse if sexual activity should change during pregnancy if no complications exist. The nurse's response will indicate that: The couple should practice coitus interruptus during pregnancy. The couple should not have sexual intercourse during the last trimester of pregnancy. It is best for the couple to avoid sexual intercourse until the woman is at least 16 weeks pregnant. Sexual desire may change but intercourse does not hurt the baby during an uncomplicated pregnancy.

Correct answer Sexual desire may change but intercourse does not hurt the baby during an uncomplicated pregnancy.

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.Which complication in the first 48 hours would priority interventions target? Shock Infection Hypothermia Curling's ulcer

Correct answer Shock

A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she stated that the adverse effects include which of the following? Epistaxis Bleeding gums Slow pulse Petechiae

Correct answer Slow pulse

Which of the following is the most appropriate diet for a client during the acute phase pf myocardial infarction? Liquids as desired. Small, easily digested meals. Three regular meals per day. Nothing by mouth.

Correct answer Small, easily digested meals.

The client who experiences angina has been told to follow a low cholesterol diet. Which of the following meals would be best? Hamburger, salad, and milkshake. Baked liver, green beans and coffee. Spaghetti with tomato sauce, salad and coffee. Fried chicken, green beans and skim milk.

Correct answer Spaghetti with tomato sauce, salad and coffee. Score: 0 / 1

A 66 year old male client attended the A & E unit complaining of cyanosis, confusion and pleuritic chest pain. Assessment revealed temperature of 37 degrees Celsius, diaphoresis and productive cough. He was admitted to the medical ward with a diagnosis of pneumonia.Antibiotics were prescribed to reduce the client's infection. Which of the following investigations must be completed before the client's antibiotic therapy is commenced? Urinalysis Chest x-ray Red blood cell count Sputum examination

Correct answer Sputum examination

A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse's next action should be to: Call for the physician. Start an IV infusion. Obtain a portable chest radiograph. Draw blood for laboratory studies.

Correct answer Start an IV infusion.

When teaching a primigravid client how to do Kegel exercises, the nurse explains that the expected outcome of these exercises is to Prevent vulvar edema. Alleviate lower back discomfort. Strengthen the perineal muscles. Strengthen the abdominal muscles.

Correct answer Strengthen the perineal muscles.

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem? Climb the steps early in the day. Rest for at least an hour before climbing the stairs. Take a nitroglycerin tablet before climbing the stairs. Lie down after climbing the stairs.

Correct answer Take a nitroglycerin tablet before climbing the stairs.

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.Which of the following immunization vaccines would be included in the patient's management? Rubella Varicella Hepatitis B Tetanus Toxoid

Correct answer Tetanus Toxoid

How would the mother of a neonate know that her infant is having sufficient breast milk? The baby is passing formed stool. The baby has at least 6 to 8 wet diapers per day. The baby appears content and is satisfied after most feedings. The baby appears to be swallowing.

Correct answer The baby has at least 6 to 8 wet diapers per day.

Which of the following applies in the planning of nursing for the patient whom the physician has written a Do Not Resuscitate (DNT) order? The client may no longer make decisions regarding his or her own health care. The client and family know that the client will most likely die within the next 48 hours. The nurse will continue to implement all treatments focused on comfort and symptom management. A DNR from the previous admission is valid for the current admission.

Correct answer The nurse will continue to implement all treatments focused on comfort and symptom management.

A client experiences initial indications of excitation after an IV infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having: Palpitations Tinnitus Urinary frequency Lethargy

Correct answer Tinnitus

A diagnosis of latent tuberculosis (TB) requires: No treatment as the client feels fine. Treatment to prevent active TB Treatment for active TB. Isolation precaution.

Correct answer Treatment to prevent active TB

Which of the following vitamins would the nurse suggest to the antenatal client would BEST aid the absorption of iron which the client is required to take during pregnancy? Vitamin A Vitamin B Vitamin C Vitamin K

Correct answer Vitamin C

A child with umbilical hernia is scheduled for surgical repair in two weeks. The clinic nurse instructs the parents about the signs of possible hernia strangulation. The nurse tells the parents that which sign would require physician notification? Vomiting Diarrhea Fever Constipation

Correct answer Vomiting

In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine virginal delivery with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse in 6 weeks when the episiotomy is completely healed. after a postpartum check by the health care provider. whenever the client is feeling amorous and desirable. when lochia flow and episiotomy pain have stopped.

Correct answer when lochia flow and episiotomy pain have stopped.