Semester 1 Previously missed questions

A client in labor is not progressing and the health care provider elects to use forceps. A pudendal block is prescribed and implemented. The client asks what the block does. Which statement made by the client indicated a good understanding of a pudendal block? A. This stops the pain around my vagina, so i dont feel the forceps B. This will make me stop wanting to push C. This medication has the same effect as an epidural or a spinal D. This block will decrease the need for an episiotomy

A

A nurse massages a postpartum clients uterus. Which finding is a cause of concern for the nurse? A. Spurting bright red blood during uterine contraction B. Dark brown blood C. A trickling of blood after the massage D. A moderate bright red blood after the brown drainage

A

The nurse cares for a client in active labor. The client states, "my back is killing me" and rates pain 10/10. She has an epidural in place, but it has not been effective for relieving back pain. Sterile vaginal exam reveals 8 cm dilated, 100% effaced, +1 station, and ROP position. Which nursing intervention leads to relief of the back pain? A.Assist the client into an all fours position. B.Have the client sit up and begin pushing. C.Notify the health care provider for an epidural bolus. D.Apply counterpressure to the lumbar area.

A

The nurse notes that the babinski reflex is absent in a newborn. Which action is most critical for the nurse to perform? A. Document and refer to the provider B. This is a normal finding at birth, no action is needed C. ensure that seizure precautions are in place D. Assess the clients blood glucose and ensure adequate oral feeding

A

The nurse provides teaching parents of a newborn about nonnutritive sucking and pacifiers. Which statement by the parent causes the nurse to be concerned? A. My baby will not have a pacifier or suck their thumb or finger B. Pacifier use may. Help prevent SIDS C. My baby likes the hospital pacifier. Where can i purchase one? D. I will wait until breastfeeding is well established to offer a pacifier

A

The nurse teaches the client with cystitis prescribed 160mg trimethoprim/800mg sulfamethoxazole orally every 12 hours. Which responses by the client indicate understanding? SATA A. I will wear sunscreen and protective clothing when outside B. This medication is safe even though i am allergic to penicillin C. It is important to take this type of medicine until it is all gone D. I will take stool softeners and drink extra fluids to prevent constipation

A, B, C

A client is assessed via external intermittent auscultation. The nurse identifies which characteristics as a part of this practice? SATA A The intensity of the contraction B The frequency of the contraction C. The mothers response to the contraction D. The resetting tone between contractions E. The mothers position during labor F. Fetal status during contractions

A, B, D, F

The nurse cares for a client 48 hours after cesarean birth. Her abdominal pain cad been managed by a combination of hydrocodone with acetaminophen and ibuprofen. The client tells the nurse "I just had pain medicine an hour ago, but i still have a lot of pain, 7/10. It is cramp and feels like gas.." What non-pharmacological interventions are appropriate? SATA A. Lie on your left side to see if you can expel gas B. I will stand by you while you go for a walk C. When you breastfeed your baby, rock in the rocking chair D. I will take the straw and ice out of your water cup E. I will bring you simethicone chewable tablets F. Refrain from drinking some the next 24 hours

A, b, c, d, f

The nurse in the ED provides discharge teaching to a client to include safe ambulation in the home over the next few days and intake at least 8 glasses of water daily. What assessment findings led the nurse to this plan for the client? SATA A> poor skin turbot B. Dry mucous membranes C. Decreased urination D. Edema to lower extremities E. Sunken eyes

A, b, c, e,

The school nurse prepares a workshop for fathers of boys in high school. The nurse has been tasked to encourage health promotion behaviors and healthy father-son relationships. The nurse includes which interventions in the teaching? Select all that apply. A."Eat a balanced diet including decreasing consumption of steak and hamburger." B."Painfulness and urgency to urinate are not common behaviors and should be discussed with a healthcare provider." C."High fiber foods, fruits and vegetables should be components of each meal." D."Safe sexual practices can prevent the incidence of prostate cancer in the long term."

A,b,c

The nurse develops a discharge plan for a client with ulcerative colitis status post-surgical bowel diversion. It is essential for the nurse to coordinate care with which members of the healthcare team? Select all that apply. A.Social worker. B.Chaplain. C.Wound care nurse. D.Psychologist. E.Child life specialist.

A,c

A client who is pregnant is screened for group b strep. Which stool should the nurse include in the POC related to the screening and management of this disorder. SATA A. Provide IV prophylaxis during labor B. Schedule oral antibiotics to the neonate C. Screen all clients at 35-37 weeks gestation D. Offer IV prophylaxis to those not screened E. With old treatment for clients with c-sections if their membranes rupture F. Provide 10 days of antibiotics to clients post-deliveru

A,c,d

The nurse assesses a primiparous client which ruptured membranes in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which interventions should the nurse perform? SATA A. Administering oxygen via mask B. Questioning the client about the effectiveness of pain relief C. Placing the client on her side D. Readjusting the monitor tot a more comfortable position E. Applying an internal fetal monitor

A,c,e

An experienced nurse supervises a new nurse during oral medication administration with a client with a history of intermittent confusion. Which practices by the new nurse should concern the experienced nurse? Select all that apply. A.The new nurse leaves the medication at the bedside while the client is in the bathroom. B.The new nurse uses the barcoding mechanism to ensure safe administration of the medication. C The new nurse uses a single method to verify the client's identity. D.The new nurse checks the picture on the identification band to verify the client's identity. E.After giving the medication the new nurse check's the client's mouth for retained medications. F.The new nurse provides milk for the client to drink and swallow their medications.

A,c,f

The nurse assesses fetal heart rate patterns for a client in active labor. The baseline FHR is 140/min but drops to 100/min intermittently for 15 seconds and returns to baseline within 30 seconds. What action is needed? A. Change maternal position side to side B. Prepare for ac-section C. Notify the health care provider D. Document as variable decelerations

A.

A client states that she has significant pregnancy induced vomitting and nausea. She has been unable to keep food or drink down for several days. She denies voiding in several hours. Which intervention would the nurse complete first? A. Provide prescribed antiemetics B. Establish an IV C. Attempt oral rehydration with electrolyte solutions D. Initiate enteral feedings via NG tube

B

The nurse cares for a client who has an open reduction internal fixation to their left foot. What information is most important for the nurse to communicate with the PR before initiating stimulation therapy? A. The client has an orthopedic boot in place B. Client reports pain 4/10 to left foot C. Clients steri-strips have dried serosanguinous drainage D. The client uses a cane at home

B

The nurse is managing care for several clients at a diabetic treatment center. The nurse understands that which of the following is the priority nursing intervention? A.To administer the correct medicine to the correct client at the correct dose and the correct time via the correct route B.To return the client to an optimum level of wellness while limiting adverse effects related to the client's medical diagnosis C.To include any cultural or ethnic preferences in the administration of the medication D.To answer any questions the client may have about the medicine, or any possible side effect of the medication

B

A client is admitted to the high risk antepartum unit with preeclampsia. The nurse directs the UAP to set up seizure precautions. Which precautions would be included? SATA A. Bite block at bedside B. Pad the side rails C. Oxygen set up at the bedside D. Suction set up at bedside E. Elevate the bed to they highest position F. Maintain the side rails up when not supervised

B, C, D, F

A client is being assessed in the Emergency Department. Which abdominal sounds does the nurse recognize as normal? A.Flat. B.Dull. C.Tympany. D.Resonance.

C

A preceptor is instructing a new nurse on delegation to an UAP. The new nurse is assigned to care for 6 clients today. Which should the preceptor question if the new nurse chooses to delegate this task? A. Emptying a clients ileostomy pouch B. Performing a skin assessment on a newly admitted client C. Feedings a client whose liquids must be thickened D. Repositioning a client with several drains and tubes

C

Assessment reveals that the fetus of a multigrain client is at a +1 station and 8 cm dilated. Based on this data the nurse should first: A. Ask the anesthesiologist to increase the epidural infusion rate B. Assist the client to push If she feels the need to do so C. Encourage the client to breathe through the urge to push D. Support family members in providing comfort measures

C

The nurse initiates a POC for a client who is admitted to the unit. The nurse writes a goal "Client will be maintained in a private room on contact isolation until lab testing shows client is free of infection." What client condition prompted the nurse to write this goal in the POC? A. UTI with E. coli B. Fever of 101.4 that has an unknown etiology C. MRSA in a wound D. Pneumonia that has been persisting for the past 6 days

C

Which prescribed pain medication would the nurse administer to a client who is in severe pain and requiring fast relief? A. Morphine 10 mg PO B. Hydro morphine 1 MG IM C. Ketorolac 30 IV D. Acetaminophen325 mg Suppository

C

The nurse observes a visiting family member deliver a client, with T2D a breakfast of pancakes, eggs, orange juice, and sugar free syrup. Which statements are most appropriate for the nurse to make to the family?SATA A. Before you begin eating please remember to self administer your insulin B. Feel free to go downstairs and eat together but please put on non skid socks C. Are you familiar with how many carbs are in this meal? D. You should not be eating this many carbs when you have diabetes E. Let's check your blood sugar level befor you eat

C, E

A nurse provides education for a group of elderly clients about managing the pain associated with osteoarthritis with non-steroidal anti-inflammatory drugs. In teaching clients about these medications, the nurse is careful to teach about how to monitor for side effects. Which side effect is of special concern and needs to be emphasized with older adults? A.Tachycardia and palpitations. B.Polyuria and tendency for dehydration. C.Elevated body temperature. D.Gastrointestinal upset or distress.

D

An older adult client is bought to the emergency department after falling in the bathroom at home and fracturing a hip. The nurse and the client are alone in the room and while assessing the client, the nurse smells a very strong odor of urine on the client's clothing, but the client denies incontinence. How might the nurse interpret this finding? A.The smell of urine is coming from somewhere else. B.The client is wearing clothing that was not washed. C.The client did not know that urine was in the clothing. D.The client is incontinent but embarrassed to admit it.

D

The charge nurse of the overflow MedSurg unit plans assignments for the next shift. Which nurse should the charge nurse assign the care of a client with bacterial conjunctivitis? A. An LPN with a client with vancomycin- resistant enterococcus B. An RN with a client status post cardiac catheterization C. An RN with a client 4 hours post op craniotomy D. An LPN with a client with diabetes

D

The emergency room nurse cares for a client who presents with pruritus and generalized erythema after his company provided a new work uniform. What priority comfort measure does the nurse provide for this client? A.Place the client on contact precautions. B.Apply topical non-prescribed lotion to client's arms and legs. C.Place the client in a hospital gown. D.Administer cool, moist compresses to areas of pruritus.

D

The nurse assists the client to the bathroom, and when the client urinates, the nurse notes that the urine is cloudy, has blood, and is foul-smelling. The client reports burning and pain with urination and says, "This is the 4th time I've urinated in the past hour, and my lower back really hurts." What additional nursing assessment is appropriate for the nurse to perform? A.Assessing the quantity of urine and documenting the output. B.Examination of the client's genitals for source of bleeding. C.Collecting urine and sending to the lab for testing. D.Percussion for costovertebral tenderness.

D

To reduce the effect of a prescribed medication on the infant of a breastfeeding mother, how should the nurse teach the mother to take the medication? A.At night B.Immediately before the next feeding C.In divided doses at regular intervals around the clock D.Immediately after breastfeeding

D