final hesi exit
A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant?
"Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air."
The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure?
Increased restlessness
A health care provider informs a client that midazolam (Versed) will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response?
Induces sedation.
A new father tells the nurse that he is anxious about not feeling like a father. What is the priority nursing action to meet this father's needs?
Providing time for the father to be alone with and get to know the baby
A nurse is caring for a client at 42 weeks' gestation who is having a contraction stress test (CST). What does a positive result indicate?
The function of the placenta has diminished
The condition of a child dying of leukemia deteriorates and the child becomes comatose. The parents state that a relative told them that they should not allow the child to be resuscitated, but they are unsure. Which response by the nurse best demonstrates recognition of the ethical issues involved?
"The final decision must be made by you and your doctor, but it's important to talk about it."
The clinic nurse is teaching the parents of a 3½-year-old child who is up to date on all vaccinations when it will be necessary to return to the clinic for the next set of vaccinations. Which statement indicates that the parents understand the teaching?
"We need to come back to the clinic in 1 year for more vaccinations."
On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use?
Focusing
At 22 weeks' gestation a client visits the prenatal clinic for the first time. As part of the prenatal workup, the client has blood work performed. The nurse concludes that further assessment is indicated when the laboratory findings show a:
Hemoglobin of 10 g/dL
A parent of a 7-year-old child asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent differentiates rubeola from rubella?
High fever and Koplik spots
A nurse is performing discharge teaching for a client who has been receiving disulfiram (Antabuse). What statement indicates to the nurse that the client understands the teaching concerning disulfuram?
should wait at least 8 hours after taking this pill before drinking alcohol."
A teenager has a prescription for oral solution levofloxacin (Levaquin) to treat a sinus infection, and the nurse explains when the medication should be taken. The nurse concludes that the teaching has been effective when the teenager says:
"I should take the medication 1 hour before a meal."
A premenopausal client is scheduled for a total abdominal hysterectomy. Which statement indicates to the nurse that the preoperative teaching has been understood?
"I won't have any more menstrual periods after this surgery."
A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response?
"You are having difficulty deciding what to say."
A married couple has been using oral contraceptives to delay pregnancy. When the wife misses her regular menstrual period, she decides to find out whether she is pregnant. She tells the nurse that pregnancy may have occurred because she missed her contraceptive pills for 1 week when she had the flu. How should the nurse respond?
"You may be correct. The effect of contraceptive pills depends on their being taken on a regular schedule."
While performing shallow, rapid breathing during transition, a client in labor experiences tingling and numbness of her fingertips. The nurse encourages her to breathe into
A paper bag
A nurse in the birthing room is assessing a newborn. Which characteristic should be assigned an Apgar value of 2?
A strong cry
A nurse is assessing a newborn in the nursery. What type of respirations does the nurse expect to identify in a healthy newborn?
Abdominal and irregular
A client who is receiving phenytoin (Dilantin) asks why folic acid (Folate) was prescribed. What is the best explanation by the nurse?
Absorption from foods is inhibited.
A nurse is teaching a pregnant client with type 1 diabetes at her first visit to the clinic how to minimize fetal/neonatal complications. What is the most important action for the client to take?
Adhere to the management plan
A client is admitted to the hospital for medical management of acute pancreatitis. Which nursing action is most likely to reduce the pancreatic and gastric secretions of a client with pancreatitis?
Administering prescribed anticholinergic medication,
When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with his or her own feelings about abortion, death, and loss so that he or she may:
Allow the clients to express their grief.
A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?
Applying sterile, moist nonadherent dressings to the sac
How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment?
Asymmetry of the gluteal folds
The parents of a 3-month old infant who is breastfed ask the nurse how to prevent nutritional anemia. What is the best response by the nurse?
Baby cereal or an iron supplement should be given around 4 months of age
A nurse is caring for a postpartum client who had abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring?
Bleeding at the venipuncture site
A nurse determines that a newborn has a cephalhematoma. What did the nurse note?
Bleeding between the parietal bone and periosteum confined within the suture line
A client receiving chemotherapy asks the nurse why an antibiotic was prescribed also. Which tissue affected by chemotherapy should the nurse consider when formulating a response?
Bone marrow
A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?
Breaks down the bilirubin into a conjugated form
A nurse is reviewing a postmenopausal client's history, which reveals that the client previously received hormonal replacement therapy (HRT) as treatment for osteoporosis. For which problem does HRT increase the client's risk?
Breast cancer
A nurse is assessing a newborn. Which sign should the nurse report?
Breathing pattern with recurrent sternal retractions
A nurse is caring for a client who was admitted with the diagnosis of severe preeclampsia and is now receiving an intravenous infusion of magnesium sulfate. What is the classification of this medication?
Central nervous system depressant
The major improvement in body image following early fitting with a prosthesis after amputation usually is related to the:
Client's improved functional abilities
A nurse performs full range of motion on a client's extremities. When putting an ankle through range of motion, the nurse must perform
Dorsiflexion, plantar flexion, eversion, and inversion
A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is:
Edrophonium chloride (Tensilon) test
What should the nurse emphasize in a class about childbirth?
Education, exercise, and breathing techniques
A nurse in the pediatric clinic is examining the throat of a 5-year-old child. The tongue blade is placed to the side of the child's tongue. The nurse uses this technique to avoid:
Eliciting the gag reflex
A 5-year-old child is being given dactinomycin (Cosmegen) and doxorubicin (Adriamycin) therapy after nephrectomy for Wilms tumor. What should the nursing care include?
Ensuring meticulous oral hygiene
A postpartum client is changing her female newborn's diaper, sees what appears to be red-tinged mucus on the diaper, and calls the nursing station for assistance. What nursing intervention is necessary?
Explaining that this is a normal reaction to the mother's hormones
A client is to have a parotidectomy to remove a cancerous lesion. For which postoperative complication that may be permanent should the nurse monitor?
Facial nerve dysfunction
what medication does a nurse expect to administer to control bleeding in a child with hemophilia A?
Factor VIII concentrate
A pregnant client who is scheduled for a nonstress test (NST) asks a nurse how the test can show that "my baby is all right." The nurse explains that it is a way of evaluating the condition of the fetus by comparing the fetal heart rate (FHR) with:
Fetal physical activity
A nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider?
Flaring nares
A pregnant client who is a strict vegetarian (vegan) asks the nurse if there is anything special she should do in relation to her diet. What should the nurse recommend?
Including specific nonanimal proteins in her daily diet
Where should the nurse place a pillow or sandbag to prevent external rotation of a lower extremity?
Lateral to the client's affected hip
The nurse anticipates that the family of a child with cerebral palsy is at risk for difficult parenting issues. What does the nurse conclude is the probable basis for this difficulty?
Loss of the expected healthy child
A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. What condition does the nurse suspect that this result indicates?
Neural tube defect
The nurse determines that a client with a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia) when the client exhibits:
Paroxysmal hypertension and bradycardia,,
A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution?
Place a surgical mask on the client.
A nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight?
Placing the naked infant on the scale
A nurse is caring for a 6-year-old child with a diagnosis of glomerulonephritis. The child's urine output decreases to less than 100 mL/24 hr, the creatinine clearance is 60 mL/min, and there is an irregular apical pulse. A diagnosis of acute renal failure is made. Blood is drawn for testing. Which serum level requires immediate intervention?
Potassium 6.1 mEq/
What behavior does a nurse expect of a newborn about 1 hour after birth?
Relaxed and sleeping quietly
Alprazolam (Xanax) is prescribed for a client who is anxious. For what therapeutic effect should the nurse monitor the client?
Resting quietly
The nurse is caring for a 1-hour-old newborn. Which assessment characteristics represent a preterm gestational age?
Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo: abundant
While performing a physical assessment of an infant with hypertrophic pyloric stenosis (HPS) the nurse observes visible peristaltic waves. What other sign of HPS should the nurse expect?
Small mass in the right upper quadrant
A female client who is undergoing infertility testing is taught how to examine her cervical mucus. After listening to the instructions the client says, "That sounds gross. I don't think I can do it." What does the nurse conclude from this statement?
Some women are uncomfortable with touching their genitals.
When the electronic fetal monitor shows contraction occurring every 2 minutes and lasting 95 seconds, the nurse should immediately:
Stop the pitocin infusion.
While performing a newborn assessment for a male infant after a scheduled cesarean birth, the nurse notes that the infant's head circumference is 4 cm smaller than his chest circumference. What does this finding indicate?
The infant's head size is smaller than average..
A 12-year-old girl is hospitalized for treatment of newly diagnosed type 1 diabetes. A teaching program for the child and her parents is planned. What should cause the nurse to be concerned about the effectiveness of the program?
The parents are having difficulty accepting the diagnosis
A male born at 28 weeks' gestation weighs 2 lb 12 oz. What does the nurse expect to note when performing an assessment?
Transparent red skin
What is the safest position for a woman in labor when the nurse notes a prolapsed cord?
Trendelenburg
What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations?
Use tactile stimuli on the chest or extremities.
The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?
Voids six or more times a day
A child is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. The nurse concludes that isolation:
Will be necessary for 24 to 72 hours after the initiation of antibiotic therapy,,
A nurse in the prenatal clinic determines the fundal height of a healthy multipara at 16 weeks' gestation to be one fingerbreadth above the umbilicus. What should the nurse do next?
Check for two distinct fetal heart rates
A 6-year-old boy is hospitalized with an exacerbation of nephrotic syndrome. The mother asks the nurse what she should bring for her son to play with during the hospitalization. What should the nurse suggest?
Checkers, simple card games, and crayons,
A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention?
Checking the child's level of consciousness hourly
The parent of a 9-year-old child who has undergone tonsillectomy is receiving discharge instructions. Which statement indicates to the nurse that the parent needs further teaching?
Cherry milkshakes will ease the pain."
A nurse is teaching a group of parents about communicable diseases. What information about chickenpox should the nurse include?
Chickenpox is communicable until the vesicles have dried."
Chelation therapy with calcium disodium edetate (EDTA) has effects besides the desired effect of removing lead from the blood. What side effect should the nurse anticipate?
Hypocalcemia
What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?
Testing for congenital syphilis
What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate?
They have a tendency to collapse with each breath
A nurse who is assessing a newborn 3 minutes after birth remembers that the heart rate of a healthy, alert neonate may range between:
110 and 160 beats/min
A nurse is teaching a family planning class about ovulation and conception. The nurse should instruct the class that the ovum is thought to be viable for what period of time after ovulation?
24 to 36 hours
per minute. The directions state that 500 mg of the drug should be added to 500 mL of D5W. At what rate should the nurse set the volume control device to administer the medication correctly? Record the answer using a whole number.
60__ mL/hr
A client with myasthenia gravis improves and is discharged from the hospital. Discharge medications include pyridostigmine (Mestinon) 10 mg orally every six hours. The nurse evaluates that the drug regimen is understood when the client says, "I should: Set my alarm clock to take my medication."
8.
A nurse is obtaining a health history from the mother of a 2-month-old infant with a diagnosis of hypertrophic pyloric stenosis (HPS). What is the most significant finding about the cause of the infant's HPS?
A first cousin underwent surgery for HPS.
When a client who had an above-the-knee amputation (AKA) complains of phantom limb sensations, the nursing staff should:
Describe the neurological mechanisms in language that the client understands
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn?
In utero through the placenta
The nurse is admitting a client to the unit after fetal death was confirmed by ultrasound. While initiating intravenous therapy the nurse notes blood continually oozing from the puncture site. What is the nurse's next action?
Informing the health care provider of this finding
The plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. How does a nurse determine that the desired effect of therapy has been achieved?
Mobility increases
A nurse is assessing several postpartum clients. Which problem does the nurse identify that will most likely predispose a client to postpartum hemorrhage?
Multifetal pregnancy,,
A nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. What blood type does the mother usually have to cause this incompatibility?
O..
A 28-year-old woman seeks advice about oral contraceptives from the nurse in her company health office. What should the nurse tell her if she is a smoker?
Oral contraceptives can cause thrombophlebitis.
A nurse is planning a conference for parents of school-aged children with sickle cell anemia. Which common concern of most parents of children with sickle cell anemia should the nurse address at the conference?
Sharing feelings regarding the transmission of the disorder
A nurse teaches a client about osteoporosis. Which client statement supports the nurse's conclusion that the teaching is effective?
"I know that certain illnesses can affect my body's calcium level."
A school nurse is teaching a class of school-age children about bicycle safety. The nurse determines that a child needs further teaching when the child states:
"I will always wear a helmet and ride with traffic facing me."
While awaiting the biopsy report before removal of a tumor, the client reports being afraid of a diagnosis of cancer. How should the nurse respond?
"It is very upsetting to have to wait for a biopsy report."
A 9-year-old child with cerebral palsy is to be taught the four-point alternate crutch gait. The parents ask why this gait was chosen. How should the nurse respond?
"It provides for equal but partial weight-bearing on each limb."
A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want her to know about the diagnosis." How should the nurse respond?
"Let's talk about how you're feeling about your child's diagnosis."
A client will be receiving monthly intramuscular doses of cyanocobalamin (Vitamin B12), 200 mcg. The medication is available as 100 mcg/mL. Which syringe contains the correct amount of medication for the ordered dose?
2ml
The nurse assesses a newborn, using the Apgar scale. One minute after birth the newborn has a heart rate of 120 beats/min, slow and irregular respirations, a weak cry, some flexion of extremities, and a pink body with blue extremities. What does the nurse record as the 1-minute Apgar score?
6
A client at 32 weeks' gestation is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiologic response indicates to the nurse that the magnesium sulfate is having a therapeutic effect?
A decrease in frequency and duration of contractions
The nurse is providing preoperative teaching to a client that is scheduled for an electromyography of the leg. What should the nurse include in the education?
A needle will be inserted into the muscle being tested
A nurse is teaching a childbirth preparation class. What information about discomfort during labor should the nurse include?
Comfort measures are available when the discomfort of contractions becomes excessive.
nurse observes bright red blood in a client's nasogastric drainage four hours after a subtotal gastrectomy. What is the next nursing intervention?
Continue to monitor the drainage and document observations.
A nurse is caring for a 9-year-old child with juvenile idiopathic arthritis (JIA). What is most important for the nurse to attempt to prevent?
Contracture deformities
A client admitted with preeclampsia is receiving magnesium sulfate. Which assessment finding indicates that a therapeutic level of the medication has been reached?
Deep tendon reflexes of +2
Following a motor vehicle accident a client reports seeing frequent flashes of light. Which condition should the nurse suspect?
Detached retina
A client exhibits persistent pyrexia, abdominal pain, and symptoms of neuritis. A diagnosis of polyarteritis nodosa is suspected. Which adaptation should the nurse expect when assessing the client?
Elevation in blood pressure
A nurse is caring for a client with a history of treatment for preterm labor during this pregnancy. The client now is at 33 weeks' gestation. With regard to sexual intercourse, the nurse should explain that it is:
Eliminated to prevent stimulation of uterine activity
What clinical finding does the nurse expect when assessing a client with myasthenia gravis?
Fluctuating weakness of muscles innervated by the cranial nerves.
A nurse is caring for a school-aged child with nephrotic syndrome who has massive edema. The nurse teaches the parents about the low-sodium diet that has been ordered. Which food group has the lowest level of sodium compared with the other food groups?
Fresh fruit
What prenatal teaching is applicable for a client who is between 13 and 24 weeks' gestation?
Growth of the fetus, personal hygiene, and nutritional guidance
The four essential components of labor are powers, passageway, passenger, and psyche. Passageway refers to the bony pelvis. What type of pelvis is considered the most favorable for a vaginal delivery?
Gynecoid
A 4-year-old child who has never been separated from parents or siblings is admitted to the hospital. What is most important for the nurse to encourage the parents to do?
Have one of them stay with the child
A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis?
Hypoxia
A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which of the following is a priority nursing intervention?
Immobilize the client's head and neck
An adult client is brought to the emergency department by a friend who states, "We were all partying at a club, and all of a sudden my friend collapsed." Vital signs revealed a temperature of 99.2, pulse of 152, respiratory rate of 32, blood pressure of 163/92. After performing a physical assessment, and collecting a health history from the client, what action should the nurse take next?
Inform the health care provider of the client's status and prepare to start an intravenous (IV) line.
A multigravida in active phase of labor says, "I feel all wet. I think I urinated." What should the nurse do first?
Inspect her perineal area.
Which information should be included in the teaching plan for the client who is prescribed sumatriptan (Imitrex) for migraine headache?
Is contraindicated in people with coronary artery disease
When planning nursing care for a 5-year-old child with acute post streptococcal glomerulonephritis, what should the nurse emphasize that the child and family must maintain?
Isolation from children with infections
A pregnant client interested in childbirth education asks how the Lamaze method differs from the Read method. What should the nurse explain about the Lamaze method?
It provides relaxation and techniques that can be used during labor
A nurse is caring for several preterm infants. What precautions should the nurse take to limit the risk for retinopathy of prematurity (retrolental fibroplasia)?
Keeping oxygen at the lowest concentration necessary and discontinuing it as soon as it is feasible,,
X-ray films reveal that a client has sustained an intracapsular fracture of the left hip as a result of a fall. The client is placed temporarily in Buck's traction. When providing care, the nurse should:
Monitor for tenderness in the left calf area
A nurse is assessing the perineum of a primipara who has had a right mediolateral episiotomy. What finding associated with this type of episiotomy will influence future focused nursing assessments?
More infections
A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? Select all that apply.
Muscle rigidity Blank facial expression
A nurse is caring for a 9-year-old child in the postanesthesia care unit after craniotomy for the removal of an astrocytoma. Suddenly the child's right pupil dilates. The priority nursing intervention is:
Notifying the health care provider
An infant is admitted to the pediatric unit for surgery to correct hypertrophic pyloric stenosis (HPS). What clinical finding should the nurse anticipate when performing a physical assessment of the infant's abdomen?
Olive-sized mass in the right upper quadrant
During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client?
Palpable pulsating abdominal mass
A client at 38 weeks' gestation is admitted to the prenatal unit with preeclampsia. A loading dose of magnesium sulfate is administered, and the dosage is subsequently lowered to a maintenance dosage. What is the most important parameter for the nurse to assess while monitoring the client for magnesium sulfate toxicity?
Patellar reflex
A client with squamous cell carcinoma of the tongue is to be treated with interstitially implanted radon seeds. What is the priority consideration when the nurse is planning room placement?
Place the client in a private room because the client will emit radiation
What is the initial nursing objective for a grand multipara who has had a cesarean birth?
Prevention of hemorrhage
After an amputation, the client's residual limb is bandaged snugly throughout the postoperative period. What should the nurse identify as the primary reason for this intervention?
Promotes shrinkage.
A child with β-thalassemia (Cooley anemia) is admitted to the ambulatory care unit for a transfusion. What instruction should the nurse include in the plan of care?
Protect from infections.
A preterm infant is receiving oxygen from an overhead hood. What nursing care is required while the infant is under the hood?
Putting a hat on the infant's head
The nurse assists the health care provider to perform a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the health care provider to document?
Queckenstedt
A child with Wilms tumor is undergoing chemotherapy in a protocol that includes vincristine (Oncovin) and doxorubicin hydrochloride (Adriamycin). Which common side effect unique to doxorubicin should the nurse expect to observe in the child?
Red urine
At a routine monthly visit, while assessing a client who is in her 26th week of gestation, the nurse identifies the presence of striae gravidarum. The nurse describes this condition as:
Reddish streaks on the abdomen and breasts
D5W/0.45 NS is infusing intravenously when a 7-year-old child is returned to the pediatric unit from surgery. The postoperative prescriptions do not indicate the desired rate of infusion. What is the most appropriate action for the nurse to take?
Reduce the flow rate to keep the vein open and obtain a prescription.
A nurse explains to a client who recently had an above-the-knee amputation that two factors contribute to residual limb shrinkage. In addition to muscle atrophy, what factor should the nurse include in the explanation?
Reduction in subcutaneous fat
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching?
Replace the drainage bag with a new bag once a week.
A nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment device has been prescribed to hasten wound healing. Which nursing action is most appropriate when caring for this client?
Replace the wound sponge every 48 hours
In her 36th week of gestation, a client with type 1 diabetes has a 9-lb 10-oz infant in a cesarean birth. For which condition should the nurse monitor this infant of a diabetic mother?
Respiratory distress syndrome,
A school-aged child is to receive a blood transfusion. What should the nurse do first if an allergic reaction to the blood occurs?
Shut off the infusion
A postpartum nurse is providing care to four maternal/infant couplets. After receiving handoff report from the off-going nurse, which client will the nurse see first?
The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 12 hours after birth
A preadolescent brings home a note from the school nurse informing the parents that the child should be evaluated for scoliosis. The mother calls the school nurse to ask for a description of scoliosis. Before responding, the nurse recalls that in scoliosis:
There is a rotary deformity of the lateral curvature of the spine
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing?
Abruptio placentae
A client is receiving phenytoin (Dilantin) for a seizure disorder and heparin for a deep vein thrombosis. Warfarin (Coumadin) is added in preparation for discontinuing the heparin. Why must the nurse observe the client closely during the initial days of treatment with warfarin?
Warfarin affects the metabolism of phenytoin.
An 8-year-old child with a supracondylar fracture of the right humerus is being prepared for surgery. What clinical finding related to the fracture should the nurse report immediately?
Weak radial pulse in the right wrist
The nurse is caring for a first-time mother at her first prenatal visit. The client confides, "I'm not sure about all this." Which research-based knowledge guides a nurse regarding the emotional factors of pregnancy?
Ambivalence and anxiety about mothering are common.
A client has cataracts in both eyes. The plan is to extract the left cataract. What should the nurse include in the client's postoperative teaching plan?
Apply a hard patch over the left eye for six to seven days after surgery
Which alternative therapy may be beneficial for the nurse to discuss with a client who has terminal bone cancer?
Biofeedback
A newborn has an asymmetric Moro reflex. What does a nurse identify as a cause of this problem?
Brachial plexus, clavicular, or humeral birth injuries
A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure?
Widening pulse pressure
A preschool-aged child with leukemia who is undergoing chemotherapy is susceptible to rectal ulcerations. What should the nurse recommend to the parents that will lessen the severity of this problem?
Clean the child's perianal area after each bowel movement.
During the physical assessment of a recently born neonate, the nurse palpates the infant's femoral pulses. For which cardiac defect is the nurse looking?
Coarctation of the aorta
A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate?
Fluctuating weakness of muscles innervated by the cranial nerves
A client with a seizure disorder is receiving phenytoin (Dilantin) and phenobarbital (Barbital). What client statement indicates that the instructions regarding the medications are understood?
"Stopping the drugs can cause continuous seizures and I may die."
Two second-graders are brought to the school health office after a fight during gym class. What should the school nurse say to the children?
"Tell me what happened."
The nurse teaches a pregnant client about fetal growth and development. Which statement indicates that the client needs further teaching?
"The fetus gets nutrients from the amniotic fluid."
A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer?Include a leading zero if applicable. Record your answer using one decimal place. _____ mL
0.6 mL
A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical manifestation of meningeal irritation for which the nurse assesses the client is:
1 Kernig's sign
A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel:
Angry
A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication should the nurse administer?Include a leading zero if applicable. Record your answer using one decimal place. _____ mL
1/2 mL
After surgical repair of a urinary tract malformation, a school-aged child is to be discharged with an indwelling catheter. The nurse teaches the parents the necessary interventions if urine does not appear in the drainage bag for 1 hour or more. Place the interventions in the order that they should be performed.
1/Checking for blocked drainage tubing 2/Pressing on the abdominal wall just above the bladder 3/Offering more fluids 4/Calling the practitioner
A nurse plans to teach a 7-year-old child with recently diagnosed type 1 diabetes how to give insulin injections. What should be included in the first lesson? Select all that apply.
1/Explaining why insulin is needed 2/Providing a syringe for the child to practice manipulating 3/Seeking a return demonstration of how to give an injection to a doll
A 9-year-old child has a fractured tibia, and a full leg cast is applied. Which assessment findings should the nurse immediately report to the health care provider? Select all that apply.
1/Inability to move the toes 2/Tingling sensation in the foot 3/Fiberglass cast that is damp after 4 hours
A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. What infant safety education should be provided? Select all that apply.
1/Wash your hands before touching the newborn. 2/All client identification bands should remain in place until discharge. 3/Check the identification of staff and if there is a question of validity, call the nursing station.
Levofloxacin (Levaquin) 750 mg intravenous piggyback (IVPB) is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? Record your answer using a whole number. ___ gtt/minute
25
Daily Humulin R insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 AM. When should the nurse monitor the client for a potential insulin reaction?
Before lunch
A client who was a passenger in an automobile collision is admitted to the emergency department with rhinorrhea and bleeding from the ear. The health care provider determines that the client has a basilar head injury. What should the nurse anticipate is the initial focus of care for this client?
Antimicrobial administration
neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate?
30 to 60 breaths/min
A nurse is caring for several pregnant clients in the prenatal clinic. Which client causes the most concern because of her predisposition to placenta previa?
30 year old, gravida 6, para 5
A nurse is assessing a newborn. What finding indicates the need for follow-up care?
30-degree abduction of the infant's hips
The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds?
Back of the thigh
On a return visit to the fertility clinic a couple requests fertility drugs because, despite having a 28-day menstrual cycle and temperature readings that demonstrate an ovulatory pattern, the woman has been unable to conceive. What should the nurse explain to the couple?
An examination of semen will be needed.
A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding indicates a need for more frequent monitoring?
Ascending weakness
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing?
Ascorbic acid (Ascorbicap)
A child with celiac disease is prescribed a gluten-restricted diet. Which lunch selection for the child indicates that the parent understands the dietary instruction provided by the nurse?
Beef taco, corn, canned peaches, chocolate milk
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram? .
Assess the client's affected extremity
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram?
Assess the client's affected extremity.
The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurological assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. What is the first action the nurse should take?
Assess the client's airway
A client who has had a lumpectomy of the breast is to undergo radiation therapy. What should the nurse do at the client's first visit to the surgeon's office after the surgery?
Assess the extent of wound healing
During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of varicose veins. In light of this information, what should the nurse's assessment include?
Assessing for signs of thrombophlebitis
A 12-year-old child is admitted to the hospital for observation after sustaining a head injury. Twelve hours after the injury the child has none of the signs or symptoms of a head injury. What is the nurse's priority intervention at this time?
Assessing the level of consciousness every hour
When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship?
Assisting the client in acquiring more effective behavior
An infant is born with a life-threatening congenital heart defect and is admitted to the neonatal intensive care unit. What is the priority nursing intervention at this time?
Assisting the parents with the grieving process
A client is admitted in preterm labor. After intravenous tocolytic medications are administered, contractions cease and she is discharged. She is to receive oral terbutaline (Brethine) 5 mg every 6 hours at home. When should the nurse advise the client to take the medication?
At mealtime/with food
During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states that it is important to:
Avoid people with respiratory infections
What action should the nurse take to prevent precipitating a painful attack in a client with tic douloureux?
Avoid walking swiftly by the client.
A nurse is teaching a young primigravida about body changes during pregnancy. The nurse explains that most prenatal clients experience urinary frequency in the first trimester because of an increase in:
Bladder pressure from the enlarged uterus
A 10-year-old child who was rescued from a house fire is brought to the emergency department with burns of the extremities. During assessment of the child, what finding is of most concern to the nurse?
Burns around the mouth
How can a school nurse help determine a young child's readiness to learn?
By assessing the child's vision and hearing
During an emergency birth the fetal head is crowning on the perineum. How should a nurse support the head as it is being born?
By distributing the fingers evenly around the head
What is the most appropriate toy for the nurse to give a 6-year-old child on complete bedrest?
Coloring book and crayons
A 5-year-old child is brought to the child health clinic for a routine visit, and the nurse observes the child interacting with other children. What type of play does the nurse expect of the child?
Cooperative
A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior?
Culture shock
breastfeeding mother asks the nurse how human milk compares with cow's milk. How should the nurse respond?
Fat in human milk is easier to digest and absorb than the fat in cow's milk.
A nurse is performing an assessment on a fifth-grader who has been admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). What early clinical findings does the nurse expect to identify?
Fatigue and ecchymotic areas
To prevent or stabilize a client in heroin withdrawal during labor, which medication should be administered as ordered if the woman is nauseated, vomiting, or did not receive her daily dose at a chemical dependence center?
Dolophine (Methadone)
A multigravida of Asian descent weighs 104 lb, having gained 14 pounds during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do?
Encourage the family to bring in special foods preferred in their culture.
A nurse has just finished reviewing how anesthesia will be used during a vaginal birth for a client with class I heart disease. What type of anesthesia does the client discuss that indicates to the nurse that the teaching was effective?
Epidural regional
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent?
Evaporation
A primigravida, unsure of the date of her last menstrual period, is told by the nurse that she appears to be at 22 weeks' gestation. What data support this conclusion?
Fundus at the umbilicus..
A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical manifestation of meningeal irritation for which the nurse assesses the client is:
Help maintain the strength of the unaffected limb
nurse determines that a client who, although ambivalent, is considering an abortion because of financial difficulties and is in crisis. How should the nurse intervene to alleviate the crisis?
Helping the client express her feelings
A second-grade teacher discusses the behavior of one of the students with the school nurse. The school nurse suspects that the child has attention deficit-hyperactivity disorder (ADHD). Which finding often is associated with ADHD?
Impulsivity
A child has been found to have classic hemophilia. A nurse teaches the child's parents how to administer the plasma component factor VIII through a venous port. It is to be given three times a week. When should the parents administer this therapy?
In the morning on scheduled days
A woman who is pregnant for the first time is concerned about regaining her figure after her baby is born and wishes to diet during pregnancy. What should the nurse advise her?
Inadequate food intake can result in a low-birth-weight infant.
A client with abruptio placentae has an emergency cesarean birth. Subsequently the nurse notes bloody urine in the indwelling catheter collection bag. What impending problem does the nurse suspect?
Incisional nick in the bladder
A client who is receiving radiation therapy for bone cancer lives alone and works full time. What should the nurse encourage this client to do?
Include rest periods during the day while receiving radiation.
A 13-year-old child is hospitalized with an exacerbation of chronic bronchitis. What action should a nurse take to decrease retained secretions?
Increase fluid intake to at least 2000 mL/day.
A client who is at 10 weeks' gestation returns for her second prenatal visit. She asks why she has to urinate so often. The nurse tells her that urinary frequency in the first trimester is:
Influenced by the enlarging uterus, which is still within the pelvis
X-ray films reveal that a client has closed fractures of the right femur and tibia. In addition, multiple soft-tissue contusions are present. What is the most important nursing intervention?
Perform a neurovascular assessment of the extremity
A married couple in their 80s is living independently. They have three adult children. The husband, who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing, dressing, and meal preparation. The nurse suggests that the plan that would be the most suitable for this couple is to
Keep them in their home with a home health aide
A nurse is teaching a class for staff members working in a group home about the cognitive development of children with cognitive impairments. What concept can these children probably learn the fastest?
Large versus small
A nurse is caring for a high-risk pregnant client who has had a positive contraction stress test (CST). The nurse interprets the result to mean that
Late decelerations of the fetal heart rate are occurring with each contraction.
A client who has been taking diuretics is admitted to the hospital with hypokalemia. For which clinical findings should the nurse assess the client?
Leg weakness and muscle cramps
A client who has a diagnosis of endometriosis is concerned about the side effect of hot flashes from her prescribed medications. Which medication should the nurse explain causes this side effect?
Leuprolide (Lupron)
An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?
Say the child's name and touch the child's arm before starting care.
During the immediate posttrauma period after injury to the frontal lobe of the brain, the nurse places a client in what position?
Low Fowler
A client with a sucking chest wound has a large tight dressing over the site. The nurse understands that the purpose of this dressing is to
Maintain the appropriate pressure within the chest cavity
A nurse is caring for a client with vaginal bleeding caused by placenta previa. What is the best nursing intervention to delay the birth of the fetus?
Maintaining bed rest
During a childbirth class the nurse determines that the women understand how to use effleurage correctly when they are observed:
Massaging their abdomens gently with their fingertips
A client in labor is admitted to the birthing unit 20 hours after her membranes rupture. What complication should the nurse anticipate when assessing the character of the client's amniotic fluid?
Maternal sepsis
When caring for clients who are demonstrating manic behavior, the nurse must constantly reassess these clients' physical needs. What characteristic about these clients makes this particularly important?
May become exhausted from excessive activity
The mother of a 4-year-old boy whose family recently emigrated from Colombia arrives at the pediatric clinic with her son who has a temperature of 102.0° F (38.9° C). He is irritable and has a runny nose, a rash, and several small, irregularly shaped red spots with blue-white centers in his mouth. What illness does the nurse suspect as the cause of these sign and symptoms?
Measles
A male client with cystic fibrosis becomes romantically involved with a woman with the same disorder. He asks the nurse about the chances of having an affected child like himself. How should the nurse respond?
Men with cystic fibrosis may not be able to father children."
An 8-year-old boy with asthma is being taught breathing exercises. The nurse uses several techniques in a play situation, and the child performs a repeat demonstration for the nurse. Which technique indicates that the child needs further teaching?
Moving a cotton ball when inhaling
A client with myasthenia gravis has been receiving pyridostigmine (Mestinon). Because of inadequate symptomatic control, the health care provider begins long-term steroid therapy. What is the primary nursing intervention when steroid therapy is instituted?
Observe the client for exacerbation of symptoms
A nurse determines that a postpartum client is gravida 1, para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care?
Obtaining an order for RhoGAM
A neonate at 34 weeks' gestation is admitted to the neonatal intensive care unit. The nurse reviews the medical record and obtains the neonate's vital signs. What objective should the nurse designate as the priority?
Oxygenation will remain adequate
As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints because this may precipitate:
Pain
A 5-year-old child is admitted to the pediatric unit with a diagnosis of acute poststreptococcal glomerulonephritis. What assessment data lead the nurse to conclude that the child has a fluid volume excess?
Periorbital edema, smoky urine, headaches
A client refuses to go to the twice-a-day prescribed sessions in physical therapy. The nurse might best approach this problem by:
Planning a conference with the client, the physical therapist, and the nurse present to discuss the client's feelings
A nurse is caring for an anemic, malnourished 11-year-old child who has celiac disease. The health team develops a plan to help the parents correct their child's nutritional problems. What should the parents be encouraged to do?
Provide foods high in folic acid, iron, and vitamin B12 to correct the anemia.
A nurse working at a summer camp is informed of an outbreak of scabies. What is the classic symptom of scabies for which the nurse needs to assess the children?
Pruritic threadlike lesions in skin folds
An 85-year-old client with a history of congestive heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sim's position, receiving oxygen at 2 L/min via nasal cannula. Which action would the nurse do first?
Raise the client to high-Fowler position
To ensure accuracy when assessing a client's blood pressure, how does the nurse avoid a parallax error?
Read the manometer at eye level.
When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent?
Retinopathy of prematurity
A nurse administers sodium polystyrene sulfonate (Kayexalate) to a client. What should the nurse monitor to evaluate the effectiveness of the Kayexalate?
Serum potassium
A 9-year-old child is found to have acute glomerulonephritis after a recent infection. What microorganism should the nurse suspect as the cause of the child's current health problem?
Streptococcus
A client with a history of tuberculosis reports difficulty hearing. Which medication should the nurse consider is related to this response?
Streptomycin
A nurse who is assessing a full-term newborn elicits the Moro reflex. How is this reflex elicited?
Striking the surface of the infant's crib suddenly
Bed rest is prescribed for a client with rheumatoid arthritis. What position should the nurse include in a positioning schedule to prevent flexion deformities during the acute phase of rheumatoid arthritis?
Supine position
A nurse is planning care with a client for the recovery period after a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. What should be included among the changes that the client should expect after surgery?
Surgical menopause
After an emergency cesarean birth, the client tells the nurse that she was hoping for a "natural" childbirth but is glad that she and her baby are all right. Which postpartum phase of adjustment does this statement most closely typify?
Taking-in
After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural childbirth." Which postpartum phase of adjustment does this statement most closely typify?
Taking-in
A 3-year-old boy is found to have X-linked Duchenne muscular dystrophy. Neither parent has muscular dystrophy. Which statement indicates that the parents understand how the disorder is transmitted?
daughters may be carriers of the disease."
A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. The client's plan of care should include:
Teaching the client to use head movements to scan the left field of vision
What safety instruction should a nurse teach a 10-year-old child with diminished sensation in the legs because of cerebral palsy?
Test the temperature of the water before a bath.
A nurse is developing a teaching plan for an 8-year-old child with recently diagnosed type 1 diabetes. What developmental characteristic of a child of this age should the nurse consider?
The child will welcome opportunities for participation in self-care
Haloperidol (Haldol) 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered and agitated after a street brawl. The nurse reviews the prescription and concludes that:
The dose is more than recommended
The parents of a newborn ask the nurse about several areas of deep-blue coloring on their baby's lower back and buttocks. The nurse's response is based on the information that:
These areas usually are normal and will fade within the first year.
An 8-year-old child with cerebral palsy is admitted to the hospital for a tendon-lengthening procedure. After the surgery the parents ask a nurse why their child must wear braces and shoes for at least 12 hours a day, even while in bed. What is the best response by the nurse?
They maintain body alignment and help prevent foot drop."
A 13-year-old boy tells the school nurse that he is getting breasts. How should the nurse respond?
This is expected at your age; let's talk about it."
A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect?
Threatened abortion
A client who is pregnant with twins is told by the health care provider that she is at risk for postpartum hemorrhage. Later the client asks the nurse why she is at risk for hemorrhage. What should the nurse remember as the cause of the postpartum hemorrhage before responding in language the client will understand?
Uterine atony
A nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. What condition is most frequently associated with late decelerations?
Uteroplacental insufficiency
A nurse in the neonatal intensive care unit (NICU) is assessing visiting parents for behaviors that might indicate difficulty with bonding. The nurse determines that support may be helpful when on seeing parents:
Visiting other babies in the NICU
A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition?
Weight loss during next 2 days
A nurse is teaching the parents of a school-aged child with celiac disease about the nutrients that must be avoided in a gluten-free diet. What nutrients should the nurse teach the parents to avoid?
Wheat and oat products
A nurse is teaching a class about childbearing and contraceptive options. The nurse explains that fertilization of the ovum by the sperm occurs at a specific time. When does it occur?
When one sperm penetrates the wall of the ovum
A nurse is reinforcing previous learning about cystic fibrosis and its treatment with a 9-year-old child. What is the most suitable information for a child of this age?
Your mucus is thick because of the way your mucous glands work.
A nurse is in the process of discharging a 9-year-old boy with recently diagnosed type 1 diabetes. What parental statement indicates an issue regarding family dynamics?
"We know that our child is special, so we'll go easy on the discipline."
Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablet(s)
2
A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further instruction about the use of crutches?
Leaning axillae on the crutches to support the body's weight
A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse understands that aseptic necrosis is associated with which factor?
Loss of blood supply to the head of the femur
A nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of potential interventions for the neonate. What is the priority intervention?
Maintaining respirations
A client is admitted to the hospital for surgery to remove a benign tumor of the neck. What is the best nursing intervention to assess for wound hemorrhage after the client's surgery?
Observe the dressing at the back of the neck for the presence of blood.
In specific situations gloves are used to handle newborns whether or not they are HIV positive. When is it unnecessary for the nurse to wear gloves while caring for a newborn?
Offering a feeding
A client has left hemiplegia because of a cerebrovascular accident (also known as "brain attack"). What can the nurse do to contribute to the client's rehabilitation?
Position the client to prevent contractures.
A regimen of rest, exercise, and physical therapy is prescribed for a client with rheumatoid arthritis. The nurse should explain that the intended purpose of the regimen is to:
Prevent the crippling effects of the disease.
Examination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document?
ROA, 0 station
An 8-year-old child is admitted to the emergency department with signs and symptoms of Reye syndrome. What information from the child's history is most important for the nurse to obtain in light of the child's tentative diagnosis?
Recent viral infection
A health care provider prescribes an intravenous infusion of magnesium sulfate for a client with preeclampsia. What baseline assessment is essential before the nurse initiates the infusion?
Respiratory rate
A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She gained 50 lb during the pregnancy, and her face and extremities are edematous. What complication, which occurs in the latter part of pregnancy, does the nurse identify?
Severe preeclampsia
A client is admitted to the hospital for the surgical creation of an ileostomy. What information should the nurse include in the preoperative teaching plan?
Skin irritation at the stoma site can occur easily.
The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response?
This behavior is a common response over which the client has very little control.
Immediately after the third stage of labor a nurse administers the prescribed oxytocin (Pitocin) infusion. Why is this medication administered?
To help the uterus contract
What should the nurse do to promote early and efficient ambulation after a client has a mid-thigh amputation?
Turn the client to the prone position routinely.
A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? Select all that apply. Drink 8 to 10 glasses of water each day
Urinate immediately after sexual intercourse
A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery?
Use a pillow to keep the legs abducted.
An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. The nurse can best assess the client's pain level by
Using Wong's "Pain Faces"
A nurse is caring for a client in the first stage of labor and an external fetal heart monitor is in place. What do the tracings indicate?
Variable decelerations
A client who is receiving phenytoin (Dilantin) to control a seizure disorder questions the nurse regarding this medication after discharge. The nurse's best response is "This medication:
Will probably be continued for life."
A client at 30 weeks' gestation is admitted to the hospital with a diagnosis of low-lying placenta previa with slight vaginal bleeding. The client is stabilized, and bleeding ceases. What is the nurse's primary focus when providing discharge teaching about care at home for this client?
Avoid situations that may stimulate the cervix or uterus
A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. What is the primary focus of nursing care during this immediate phase?
Avoiding flexion or hyperextension of the spine
What actions should the nurse include when planning for the long-term care of a client with expressive aphasia?
Begin helping the client to write
A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. What complication does the nurse suspect?
Intracranial hemorrhage
A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior right leg. The practitioner prescribes morphine sulfate (Duramorph) for pain. What route of administration should the nurse expect to administer this medication?
Intravenously
A client is scheduled for a closed magnetic resonance imaging test (MRI). The client states, "I'm a little scared of small places." What is the nurse's most appropriate response?
"Mild sedation is available if you are anxious about lying in a confined area."
A client undergoes dilation and curettage (D&C) after an early miscarriage (spontaneous abortion). The nurse finds her crying later in the day. What is the most appropriate statement by the nurse?
"This must be a very hard experience for you to deal with."
The nurse is teaching the Hispanic parents of a preschool child about the prevention of lead poisoning. Which statement by the parents indicates a need for further teaching?
"We can use orange powders for diarrhea."
A client calls the nurse-midwife in the prenatal clinic, complaining of sharp shooting pains in the lower abdomen and vaginal spotting. She is met at the emergency department of the hospital, where a diagnosis of ruptured tubal pregnancy is made. At what stage of the pregnancy does the nurse suspect the initial symptoms began?
About 6 weeks into the pregnancy
The nurse is caring for a client with a long leg cast. Which clinical findings indicate compromised circulation? Select all that apply.
1. Swelling of the toes 2. Prolonged capillary refill
The nurse supports cognitive ability in clients with Alzheimer dementia by: Select all that apply.
1. Using calendars, clocks, and pictures to support memory 2. Encouraging caregivers to support protected independence 3. Providing a limited number of choices to support decision making
A health care provider plans to perform a vaginal examination of a client with a partial placenta previa. What should the nurse have available when this examination is performed?
2 units of typed and crossmatched blood
While performing a newborn assessment after a vaginal birth a student nurse observes a swelling on one side of the top of the head that does not cross the suture line. The student nurse has identified what clinical manifestation?
A Cephalohematoma
One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next?
Continue periodic assessments and record the findings.
A 24-year-old client complains to the nurse in the women's health clinic that her breasts become tender before her menstrual period. What should the nurse recommend that the client do 1 week before an expected menses?
Decrease caffeine intake.
A client with severe chronic rheumatoid arthritis reports that pain lasts for two to three hours after exercising. The nurse should teach the client to:
Decrease the total time and number of repetitions of the exercise
A client with cancer is told by a health care provider that the cancer has metastasized to other organs and is untreatable. The client tells the nurse, "I think they made a mistake. I don't think I have cancer. I feel too good to be dying." Which stage of grief does the nurse conclude that the client is experiencing?
Denial
A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse who will provide ongoing care. What should the nurse who witnessed the event do next?
Document the incident.
When changing her newborn's diaper a new mother notes a reddened area on the infant's buttock and reports it to the nurse. What should the nurse do next?
Encourage the mother to cleanse the area and change the diaper more often
A client has a cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day?
Encouraging frequent ambulation
Which action should be included in the plan of care for a client who has had pelvic surgery?
Encouraging the client to ambulate in the hallway.
The nurse has provided teaching to a client with impaired balance who uses a walker when ambulating. The nurse observes the client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client:
Holds both handles of the walker while rising to the standing position
To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis?
Ineffective coughing