practice exam
A client in active labor asks the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse?
"Changes in your blood pressure can affect the fetus." During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. Preeclampsia causes the blood pressure to increase, and low blood pressure may cause dizziness; however, neither fact explains the primary reason for frequent monitoring. Telling the client that it is policy is not a patient-centered response.
A client is receiving radiation therapy. What should the nurse teach the client about skin care?
Avoid shaving with straight-edge razors. Clients should use an electric razor, instead of a straight-edge razor, on any skin areas that are receiving radiation. The skin should be cleaned daily with a mild soap, not harsh antibacterials. Lotion should be removed from the skin before any treatment and then reapplied after the treatment. The radiated skin area needs to be kept clean, dry, and open to air.
The nurse is caring for a client postoperatively who received an inhalation anesthetic during GI surgery. The client complains of being very cold and is shivering. The nurse provides extra blankets. What additional intervention is needed
Provide oxygen as ordered. Hypothermia is a common effect of inhalation anesthetics, and shivering is normal during postoperative recovery. The nurse should administer oxygen, as ordered, to compensate for the increased oxygen demand caused by shivering. Notifying the physician would be appropriate only if the client had other signs and symptoms, such as respiratory distress or changes in skin color or vital signs. Increasing the I.V. fluid infusion rate could cause fluid overload. The nurse should monitor the fluid intake and output of all postoperative clients, not just those who are shivering or who received an inhalation anesthetic.
Which client has a greater risk for latex allergies?
a woman who is admitted for her seventh surgery Clients who have had long-term multiple exposures to latex products, such as would occur with six previous surgeries and recoveries, are at increased risk for latex allergies. The nurse should explore what types of surgeries these were, how involved the client's recoveries were, and whether signs of latex allergies have occurred in the past. Working as a sales clerk, having type 2 diabetes, and undergoing laser surgery do not expose a client to latex or increase the risk of latex allergy.
Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?
canned tomato juice Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The nurse should teach the client to read labels carefully. Apples and whole wheat breads are not high in sodium. Hamburger would have less sodium than canned foods or tomato juice.
A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess
chest movements. The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say the word "ninety-nine" the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. The nurse assesses breath sounds during auscultation.
A nurse is interviewing the parent of a 7-year-old child. Which symptom reported by the parent leads the nurse to suspect that the child has type 1 diabetes?
recent bed-wetting Polyuria, recognized by parents as bed-wetting in a child recently toilet-trained, is a hallmark of type 1 diabetes mellitus. Polyphagia is also a hallmark of type 1 diabetes mellitus. A parent is also likely to report weight loss despite excessive eating, not weight gain or a poor appetite. The child with type 1 diabetes mellitus may complain of fatigue rather than boundless energy.
