HPA III Prep U questions

A. "The drug you got to help with the nausea can cause dry mouth."

A 10-year-old who is receiving chemotherapy has received ondansetron before this therapy session. About an hour later, the child tells the nurse that his mouth feels really dry. The child has urinated several times and his skin turgor is normal. Which response by the nurse would be most appropriate? A. "The drug you got to help with the nausea can cause dry mouth." B. "Let me increase your intravenous fluids." C. "You might be having a severe allergic reaction. Are you itchy?" D. "This indicates an infection. We need to start antibiotics."

A. Lungs

A 15-year-old boy has been diagnosed with an osteosarcoma of the distal femur. He also demonstrates a chronic cough, dyspnea, and chest pain, along with chronic leg pain. Based on these findings, the nurse should suspect metastasis to which body area? A. Lungs B. Heart C. Brain D. Rib cage

B. initial BP 100/70 mm Hg; current BP 140/90 mm Hg

A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider? A. initial BP 120/80mm Hg; current BP 130/88 mm Hg B. initial BP 100/70 mm Hg; current BP 140/90 mm Hg C. initial BP 140/85 mm Hg; current BP 130/80 mm Hg D. initial BP 110/60 mm Hg; current BP 112/86 mm Hg

D. Check fetal heart rate and maternal blood pressure.

A 28-year-old multigravida at 32 weeks' gestation is admitted to the hospital because of vaginal bleeding. Which action should the nurse do first? A. Perform a sterile vaginal examination. B. Administer a cleansing enema. C. Witness a consent for immediate cesarean birth. D. Check fetal heart rate and maternal blood pressure.

A. Assess deep tendon reflexes

A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy? A. Assess deep tendon reflexes. B. Monitor intake and output. C. Assess the client's mucous membrane. D. Assess the client's skin turgor.

D. grunting

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam? A. regular respirations B. pink skin C. hypertension D. grunting

C. "knife-like" abdominal pain with vaginal bleeding

A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess? A. painless bright red vaginal bleeding B. increased fetal movement C. "knife-like" abdominal pain with vaginal bleeding D. generalized vasospasm

D. strong cry

A nurse is assessing an infant who has experienced asphyxia at birth. Which finding indicates that the resuscitation methods have been successful? A. heart rate of 80 bpm B. jitteriness C. hypotonia D. strong cry

C. Start oxytocin at 2 milliunits

A nurse is caring for a patient who was diagnosed with a placenta previa. Which order should the nurse question? A. Type and screen for 2 units of blood B. Continuous fetal monitoring C. Start oxytocin at 2 milliunits D. Prepare for cesarean section

B. Rho(D) immune globulin administration to Rh-negative women

A nurse is conducting a presentation for a group of pregnant women about conditions that can occur during pregnancy and that place the woman at high-risk. When discussing blood incompatibilities, which measure would the nurse explain as most effective in preventing isoimmunization during pregnancy? A. blood typing of mothers with type A or B blood B. Rho(D) immune globulin administration to Rh-negative women C. amniocentesis D. cerclage

A. "This situation must be difficult for you. Can you tell me what concerns you have right now?"

A nurse notices a mother in the NICU crying next to her premature 25-week-old neonate. What is the most appropriate response by the nurse? A. "This situation must be difficult for you. Can you tell me what concerns you have right now?" B. "It is important to not worry. Let's hope everything will be okay." C. "Can you share what things have made you this upset?" D. "Would you like me to call a chaplain to see you? This has been a help to others."

D. Chronic hypertension

A pregnant woman being seen for an initial visit at 18 weeks gestation has a blood pressure of 160/100. What diagnosis should the nurse anticipate? A. Preeclampsia B. Pregnancy Induced Hypertension C. Gestational hypertension D. Chronic hypertension

A. Premature separation of the placenta

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? A. Premature separation of the placenta B. Preterm labor that was undiagnosed C. Placenta previa obstructing the cervix D. Possible fetal death or injury

D. "Come to the health facility with any vaginal material passed."

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do? A. "Maintain bed rest, and count the number of perineal pads used." B. "Come to the health care facility if uterine contractions begin." C. "Continue normal activity, but take the pulse every hour." D. "Come to the health facility with any vaginal material passed."

B. Provide isolette or radiant warmer care to the newborn.

An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which intervention should the nurse consider to prevent the newborn from losing body temperature? A. Hold the newborn close, rocking gently. B. Provide isolette or radiant warmer care to the newborn. C. Administer vitamin K to the newborn. D. Give the newborn a warm water bath.

A. "do not palpate abdomen."

An important nursing intervention to institute with an infant prior to surgery for a Wilms tumor is to place a sign over his crib that reads: A. "do not palpate abdomen." B. "no milk or milk products allowed." C. "no blood sampling in lower extremities." D. "no intramuscular injections."

C. Feed the neonate.

If the nurse manages a newborn with low blood sugar, which intervention would be appropriate to prevent hypoglycemia? A. Hold all feedings. B. Check the heart rate. C. Feed the neonate. D. Give antibiotics.

A. respiratory

In the preterm newborn, the most critical complications are related to which system? A. respiratory B. digestive C. immune D. integumentary

A. Child reports facial palsy and vision problems

The nurse is assessing a 10-year-old girl with acute lymphoblastic leukemia. What information would lead the nurse to suspect that the cancer has infiltrated the central nervous system? A. Child reports facial palsy and vision problems B. Observing petechiae, purpura, or unusual bruising C. Noting adventitious breath sounds during auscultation D. Palpation of abdomen reveals enlarged liver and spleen

B. complete blood cell count (CBC)

The nurse is caring for a child admitted with suspected leukemia. The nurse has taken the child's history and performed an assessment. The nurse will plan to prepare the child for which additional diagnostic test first? A. urinalysis B. complete blood cell count (CBC) C. bone marrow aspiration D. magnetic resonance imaging (MRI)

A. preventing and alleviating pain

The nurse is caring for a client with terminal cancer who is experiencing dyspnea and increasing levels of pain. What would be the priority for pain management with this child? A. preventing and alleviating pain B. monitoring the child's vital signs frequently C. following the health care provider's rigid guidelines regarding dosages D. preventing addiction to the opioid medications

C. Talk with her and her family about wearing a wig, cap, or scarf.

The nurse is talking with a 9-year-old child diagnosed with acute leukemia who will soon begin chemotherapy. The child expresses worry that when her hair falls out friends won't like her or want to play with her anymore. Which response by the nurse would be best? A. Reassure the child that her hair will grow back in 3 to 6 months. B. Tell the child that having chemotherapy is the only way she'll get better. C. Talk with her and her family about wearing a wig, cap, or scarf. D. Distract the child with a book or educational computer games.

D. a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria

The nurse is transcribing messages from the answering service. Which phone message should the nurse return first? A. an 18-year-old, 38-week G2P1 client with intermittent cramping; the client's last blood pressure was 98/50 mm Hg, and proteinuria was 1+ B. a 25-year-old, 31-week G1P0 client with blood pressure of 100/80 mm Hg and left flank pain; the client's last blood pressure was 100/77 mm Hg and she had no proteinuria C. a 20-year-old, 31-week G1P0 client with malaise and rhinitis; the client's last blood pressure was 120/80 mm Hg, and she had no proteinuria D. a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria

B. a 19-year-old 18 weeks' intrauterine pregnancy (IUP) who is now 12 hours post motor vehicle accident with bright red vaginal bleeding

The nurse on the antenatal unit is planning care for four clients. The nurse should assess which client first: A. a 29-year-old client carrying twins, being treated for preterm labor at 29 weeks' gestation and receiving magnesium sulfate at 2 g/h, with stable fetal heart rates and no contractions for the past 2 hours B. a 19-year-old 18 weeks' intrauterine pregnancy (IUP) who is now 12 hours post motor vehicle accident with bright red vaginal bleeding C. a client at 38 weeks' gestation hospitalized frequently during this pregnancy for placenta previa and who two days ago was admitted with severe bright red vaginal bleeding that has tapered off now D. a 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours

D. the respiratory system

The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and family must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity? A. the genitourinary system B. the musculoskeletal system C. the endocrine system D. the respiratory system

D. Respiratory system

Upon shift handoff the nurse reports meconium staining of the amniotic fluid. Which neonatal system requires close monitoring by the incoming nurse? A. Gastrointestinal system B. Cardiovascular system C. Endocrine system D. Respiratory system

C. "Keep in mind that the signs of leukemia are often subtle and difficult to recognize."

What is the best response by the nurse to the parents of a child with leukemia who express guilt because they did not take immediate action when their child seemed to develop one respiratory infection after another? A. "Don't feel bad. Children get lots of colds." B. "Young children develop minor illness easily and often. Stop being hard on yourselves." C. "Keep in mind that the signs of leukemia are often subtle and difficult to recognize." D. "You need to focus on the present treatment now and not worry about the past."

D. Obtain and document baseline vital signs.

What is the first action the nurse takes in surfactant administration? A. Call pharmacy for medication. B. Change the infant's diaper. C. Hold feedings. D. Obtain and document baseline vital signs.

B. surfactant

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature? A. Rho(D) immune globulin B. surfactant C. neomycin D. heparin

B. respirations as increased and high

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? A. heart rate as normal B. respirations as increased and high C. skin as pink D. chest expansion as normal

A. Premature birth

Which condition of delivery would predispose a neonate to respiratory distress syndrome (RDS)? A. Premature birth B. Vaginal delivery C. First born of twins D. Postdate pregnancy

C. perinatal asphyxia

Which factor places newborns at risk for ongoing health problems? A. term birth B. average weight C. perinatal asphyxia D. vaginal birth

B. Iliac crest

Which site is most frequently used to perform a bone marrow aspiration? A. Humerus B. Iliac crest C. Rib cage D. Femur

A. a weak sucking reflex

While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? A. a weak sucking reflex B. a positive rooting reflex C. a positive Babinski sign D. startle reflex in response to a loud noise