dumpspedia logo
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse’s first intervention should be to:
After several days, an IDDM client’s serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of “not feeling well.” At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?
Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
The nurse practitioner determines that a client is approximately 9 weeks’ gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:
A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for:
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
Which of the following ECG changes would be seen as a positive myocardial stress test response?
When teaching a sex education class, the nurse identifies the most common STDs in the United States as:
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
A client with a C-3–4 fracture has just arrived in the emergency room. The primary nursing intervention is:
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:
The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:
When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse’s response should be based on the fact that:
Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as “a cramp in my leg.” An appropriate nursing action is to:
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:
Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, “This is too much trouble. I would rather just have a Foley.’’ An appropriate response for the RN teaching him would be:
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:
A complication for which the nurse should be alert following a liver biopsy is:
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child’s mother for the home treatment of croup?
A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being “on the move,” sleeping 3–4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele’s rule, the estimated date of confinement is:
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
While the RN is assessing a mother’s perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother’s perineum. Which one of the following interventions should the RN initiate at this time?
A first-trimester primigravida is diagnosed with anemia.
The nurse should suspect that this anemia is a result of:
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
A schizophrenic client who is experiencing thoughts of having special powers states that “I am a messenger from another planet and can rule the earth.” The nurse assesses this behavior as:
A physician’s order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:
A mother who is breast-feeding her newborn asks the RN, “How can I express milk from my breasts manually?” The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
A 1000-mL dose of lactated Ringer’s solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:
A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, “I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?’’ The RN could suggest which one of the following?
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:
On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
At 16 weeks’ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
At 30 weeks’ gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:
A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:
A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client’s responses would indicate compliance during initial therapy?
At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?
When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is “rule out hepatitis.” Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
Dietary planning is an essential part of the diabetic client’s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse’s first action when admitting the client will be to:
A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as:
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, “Nobody cares about the clients.” The nurse’s most effective response would be:
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, “The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?” The best explanation for the nurse to give the client would be that balanced anesthesia:
The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, “I get them whenever I bump into anything.” The nurse would expect to note a decrease in which of the following laboratory tests?
The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child’s case manager knows that treatment has been effective when:
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly—High risk for injury: Increased susceptibility to bleeding related to:
A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:
A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:
The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:
A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a “Trendelenburg gait.” This gait is characteristic of:
A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:
A client states to his nurse that “I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells.” Based on this information, which drug might the nurse expect to be discontinued?
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:
Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?
A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim- sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:
A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her
room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, “The doctor said I have stones that need to be removed; where are they?” The nurse knows that the best explanation for this is to tell her that:
A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will “beat out of her chest.” The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication’s effectiveness, the nurse should monitor the:
The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:
A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:
What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?
A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
Children often experience visual impairments. Refractive errors affect the child’s visual activity. The main refractive error seen in children is myopia. The nurse explains to the child’s parents that myopia may also be described as:
A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:
As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:
Nursing care for the parents of a child with a congenital heart defect would include:
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client’s pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend’s physician uses this artery. The nurse tells the client that the internal mammary artery:
The nurse documents a client’s surgical incision as having red granulated tissue. This indicates that the wound is:
The nurse assesses a client’s monitor strip and finds the following: uterine contractions every 3–4 minutes, lasting 60–70 seconds; FHR baseline 134–146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, “I haven’t exercised in 6 days. I won’t be eating lunch today.” This statement by her most likely reflects:
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig’s sign. The nurse expects her to react to discomfort if she:
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client’s diet?
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client’s best choice from the items below would be:
A client is being admitted to the labor and delivery unit. She has had previous admissions for “false labor.” Which clinical manifestation would be most indicative of true labor?
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
A female client with major depression stated that “life is hopeless and not worth living.” The nurse should place highest priority on which of the following questions?
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold’s maneuvers by having her:
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
A 26-year-old female client presents at 10 weeks’ gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client’s previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4” and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
A 14-year-old boy fell off his bike while “popping a wheelie” on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client’s sexual functioning?
While the nurse is taking a male client’s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?
A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:
The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
The nurse is teaching a mother care of her child’s spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:
The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
Which of the following signs might indicate a complication during the labor process with vertex presentation?
In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
The nurse would assess the client’s correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
Other drugs may be ordered to manage a client’s ulcerative colitis. Which of the following medications, if ordered, would the nurse question?
A nurse should carefully monitor a client for the following side effect of MgSO4:
Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration?
An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant’s mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant’s home care?
The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client’s depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?
One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse’s intervention would be to:
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life’s goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client’s feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson’s stages?
To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
A female client comes for her second prenatal visit. The nurse-midwife tells her, “Your blood tests reveal that you do not show immunity to the German measles.” Which notation will the nurse include in her plan of care for the client? “Will need . . .
A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother’s arms when the nurse approaches. Which approach is most appropriate at this time?
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
A female client is concerned that she is in a “high-risk” group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
A 6-year-old girl has been diagnosed with a urinary tract infection secondary to vesicoureteral reflux. Which statement by her mother indicates a need for further teaching?
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?
A female client at 36 weeks’ gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
An 82-year-old former restaurant owner walks to the nursing station and states, “I have to go. The restaurant opens at 11 am.” Which response by the nurse is the most appropriate?
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
A client has renal failure. Today’s lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?
A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?
A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:
A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?
A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema. Which dietary plan is most appropriate for this client?
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client’s self-esteem by:
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, “I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.” This defense mechanism is an example of:
A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?
A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the unit and was found
smoking in the bathroom and spending a large amount of time in the male ward. Which statement by the nurse would best explain to the teenager why she must follow the rules of the unit?
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
TESTED 21 Nov 2024