NURS 206 midterm review 205 Questions and Answers,100% CORRECT

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NURS 206 midterm review 205 Questions and Answers UNIT II Professional Standards in Nursing Care of Special Populations 1. Which teaching method is most effective when providing instruction to ... members of special populations? Teach-back (When providing education to members of special populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions.) 2. SATA. Which health concern(s) should the nurse be aware of as risk factors when caring for clients of African American descent? Cancer. Obesity. Hypertension. Heart disease. Diabetes mellitus. 3. The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes information about which measure that is related to a newborn complication within this ethnic group? Safe Sleeping (The Native Hawaiian population has a disproportionately higher rate of infant mortality compared with other ethnic groups. Sudden infant death syndrome (SIDS) is a major cause of infant mortality. Safe sleeping is an important measure to prevent this newborn complication. 4. The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? MSM (men-who-have-sex-with-men) 5. Which therapeutic communication technique is most helpful when working with transgender persons? Using open-ended questions (The use of open-ended questions is most helpful in communicating with transgender persons because it assists in refraining from judgment and allows the client the opportunity to express their thoughts and feelings) 6. SATA. Which special population should be targeted for breast cancer screening by way of mammography? MTF. FTM. WSM. WSW. 7. The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first? Complaints of pain associated with numbness and tingling in both feet. 8. The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? Glipizide (Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which presents a safety risk to the homeless person) 9. The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? The history (Intellectually disabled clients tend to be poor historians, and it may be necessary to take more time to ask questions in a variety of different ways when collecting the history data) 10. The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond? “Living in prison can predispose a person to different health conditions” (The environment of a prison can predispose a person to different health conditions, such as tuberculosis, human immunodeficiency syndrome, sexually transmitted infections, or other infectious diseases) 11. The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up? A reddish-purple mark on the neck (The client in this question should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise, including post-traumatic stress disorder, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self- esteem, and alcohol and drug abuse) 12. SATA. The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Sleep problems. Bipolar disorder. Aggressive behavior. ADHD. (Foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, post-traumatic stress disorder, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder) 13. The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? PTSD (Post-traumatic stress disorder (PTSD) is extremely common in this population. Identifying and treating mental health disorders assists in mitigating suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance use disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy) 14. The nurse caring for a refugee considers which health care need a priority for this client? Access to mental health care services. (Mental health problems are the primary issue for this population as a result of tortuous events) 15. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? Arranging home health care (Nursing follow-up visits are important in promoting health for individuals with chronic illness; therefore, arranging for home health care is an important strategy) Ethical and Legal Issues 16. The nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? The client was found lying on the floor. (The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse) 17. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? Transport the victim to the OR for surgery. (In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent) 18. The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? Reassess the client. (After a client’s fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall. The client’s fall should be treated as private information and shared on a “need to know” basis) 19. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. (Floating is an acceptable practice used by the hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option) 20. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? Call the nurse supervisor. (Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This occurrence needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required) 21. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? “I will call the nursing supervisor to seek assistance regarding your request” (Instructional directives (living wills) are required to be in writing and signed by the client. The client’s signature must be witnessed by specified individuals or notarized) 22. SATA. The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client’s record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Right click on the entry and modify it to reflect the correct information. Document the correct information and end with the nurse’s signature and title. Obtain a co-signature from the RN who witnessed the waste of the remaining 1mg. Document in a nurses note in the clients record detailing the corrected information. 23. Which identifies accurate nursing documentation notation(s)? A client slept through the night. Abdominal wound dressing is dry and intact without drainage. The client left lower medial leg wounds is 3cm in length without redness, drainage, or edema. Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. 24. A nursing instructor delivers a lecture to nursing students regarding the issue of clients’ rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? Observing care provided to the client without the client permission 25. Nursing staff members are sitting in the lounge taking their morning break. Assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? Slander (Defamation in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group) 26. An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? “As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay” 27. The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? Contact the RN supervisor 28. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? Call the RN supervisor and report the occurrence Prioritizing Client Care: Leadership, Delegation, and Emergency Response Training 29. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A client with asthma who requested a breathing treatment during the previous shift. (Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing.) 30. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A client with chest pain who states that he just ate pizza that was made with a very spicy sauce. 31. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? An RN leads 2 LPNs and 3Aps in providing care to a group of 12 clients. 32. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A client with a WBC 14,000 mm3 and a temp of 38.4C (101.2F) 33. The nurse is giving a bed bath to an assigned client when assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 34. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? Confront the UAP to encourage verbalization of feelings regarding the change. Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem 35. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? A client who requires urine specimen collections. 36. SATA The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Move beds away from windows. Close window shades and curtains. Place blankets over clients who are confined to bed. In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. 37. SATA The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? The acuity level of the clients. Client needs and workers needs and abilities. There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. UNIT III Foundations of Care Fluid and Electrolytes 38. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? An increase in B/P and increased RR 39. The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? Requires nasogastric suction 40. SATA The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? U waves. Inverted T waves. Depressed ST segment. Serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Hypokalemia EKG changes will include prominent U waves, shallow, flat or inverted T waves. Depressed ST segment. Thready weak irregular pulse, weak peripheral pulses, Orthostatic hypotension, dysrhythmias. It is potentially life threatening because every-body system is affected. Caused by diuretic use, increase secretion of aldosterone, vomiting diarrhea, wound drainage (GI), prolonged nasogastric suction, excessive diaphoresis, kidney disease, alkalosis, hyperinsulinism. Hyperkalemia EKG changes will include tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR interval. Slow weak, irregular HR decreased B/P, dysrhythmias. Caused due to excessive K intake and/or rapid infusion, adrenal insufficiency (Addison’s disease) antidiuretics, kidney disease, tissue damage (burns), acidosis. Hypocalcemia EKG changes will include a prolonged QT interval and prolonged ST segment. Decreased HR. Hypotension. Diminished peripheral pulses. Signs include paresthesia followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. GI symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Lactose intolerance Hypercalcemia EKG changes will include shortened ST segment, widened T wave, heart block. Increased HR in early stages and bradycardia that can lead to cardiac arrest in late stages. Increased B/P. Bounding full peripheral pulses. Signs include kidney disease, thiazide diuretics, hyperparathyroidism, hyperthyroidism, malignancy, immobility, dehydration, use of lithium, adrenal insufficiency Hypomagnesemia EKG changes will include tall T waves, Depressed ST segment. Tachycardia and hypertension. Signs and causes malnutrition, starvation, vomiting, diarrhea, malabsorption syndrome, celiac disease, Crohn’s disease, diuretics, chronic alcoholism, hyperglycemia, insulin administration, sepsis. Hypermagnesemia EKG changes will include prolonged PR interval, widened QRS complexes. Bradycardia, dysrhythmias (cardiac arrest if severe), hypotension. Signs and causes Mg containing laxatives or antacids, excessive IV admin, decreased renal excretion of Mg due to renal insufficiency. Hyponatremia can occur in the client taking diuretics. Signs are muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted. Hypernatremia occurs in the client taking corticosteroids, the client with hyperaldosteronism or Cushing's syndrome. Signs are muscle twitching, decreased urinary output, increase specific gravity of urine. HR and B/P respond to vascular volume status. Hypophosphatemia causative factors relate to malnutrition, starvation , the use of aluminum hydroxide–based or magnesium-based antacids, hyperparathyroidism, malignancy, hyperglycemia, respiratory alkalosis. Hyperphosphatemia occurs in client with renal insufficiency, hypoparathyroidism, and tumor lysis syndrome, decreased renal excretion due to renal insufficiency, increase intake of phosphate or phosphate containing laxatives or enemas, hypoparathyroidism. 41. SATA Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Obtain an intravenous (IV) infusion pump. Monitor urine output during administration. Monitor the IV site for signs of infiltration or phlebitis. Ensure that the medication is diluted in the appropriate volume of fluid. Ensure that the bag is labeled so that it reads the volume of potassium in the solution. 42. The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? Twitching. Calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). 43. SATA The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Prolonged QT interval. Prolonged ST segment. A client with Crohn's disease is at risk for hypocalcemia. 44. SATA The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Tall peaked T waves. Widened QRS complexes. The client with chronic kidney disease is at risk for hyperkalemia. Potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L) 45. Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? A client who is taking diuretics. Sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). 46. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? Hyperactive bowel sounds indicate hyponatremia. 47. The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? Malnutrition. Serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). 48. The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented “insensible fluid loss of approximately 800 mL daily.” The nurse makes a notation that insensible fluid loss occurs through which type of excretion? Integumentary output. Insensible losses may occur without the person's awareness, they occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses. 49. The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? A client with an ileostomy. Fluid volume deficit causes include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Sings are increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered LOC. Fluid volume excess is caused by decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. Sings are lung congestion, increased urinary output, and increased blood pressure 50. The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? Weight loss and poor skin turgor. 51. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? The client with kidney disease and a 12-year history of diabetes mellitus. 52. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? The client who has sustained a traumatic burn. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. Acid Base Balance 53. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 of 30 mm Hg (30 mm Hg), and HCO – of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? Respiratory alkalosis, compensated 54. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? Metabolic alkalosis 55. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding? An increased pH and an increases HCO –. 56. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, PaO2 = 72 mm Hg (72 mm Hg), PaCO2 = 32 mm Hg (32 mm Hg), and HCO –= 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? The client is hyperventilating. 57. SATA The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? RR that are increased in rate and are abnormally deep. 58. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PaCO2 is 90 mm Hg (90 mm Hg), and HCO – is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? Respiratory acidosis, no compensation. 59. SATA The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Nausea. Confusion. Tachycardia. Lightheadedness. 60. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? pH 7.25, Paco2 50 mm Hg (50 mm Hg) 61. The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? Potassium level of 3.0 mEq/L (3.0 mmol/L) Respiratory alkalosis clinical manifestations include lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities. Often caused by hyperventilation Respiratory acidosis Often caused by hypoventilation 62. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? Respiratory acidosis from inadequate ventilation Vital Signs and Lab Reference Intervals 63. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? Holding the dose of the next warfarin. A therapeutic PT level is 1.5 to 2 times higher than the normal level. PT is (11 to 12.5 seconds) greater than 25s places the client at risk for bleeding aPTT varies between (30 and 40s) The range should not be <1.5 (45s to 60s) and >2.5 (75s to 100s) when receiving heparin therapy. INR 0.8 – 1.20 A1C range <6% (adult without diabetes) BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Serum creatinine M: 0.6 to 1.2 mg/dL (53 to 106 mcmol/L); F: 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) Serum Sodium 135 to 145 mEq/L Serum Potassium 3.5 to 5.0 mEq/L Cholesterol <200 mg/dL HDLs >60 mg/dL LDLs <100 mg/dL Triglycerides M (40-160 mg/dL) F (35-135 mg/dL) Hemoglobin level for F: 12 to 16 g/dL (120 to 160 mmol/L) M: 14 to 18 g/dL (140 to 180 mmol/L) Hematocrit level for F: 37% - 47% (0.37 – 0.47) M: 42% - 52% (0.42 – 0.52) WBC 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). Platelets 150,000 to 400,000 mm3 (150 to 400 × 109/L) Neutrophils 60-70% Lymphocytes 20-25% Monocytes 3-8% Eosinophils 2-4% Basophils 0.5-1% 64. A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? I will be sure to cue into any indicators that the client may be exaggerating their pain. 65. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 15mg/dL (5.4 mmol/L) 66. The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? Taking an oral temp for a client with cough and nasal congestion. 67. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? Leaving the rate of the heparin infusion as is. 68. A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 3.2 mEq/L (3.2 mmol/L) 69. SATA Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Platelets 35,000 mm3. Sodium 150 mEq/L. Segmented Neutrophils 40%. WBC 3000 mm3. 70. SAT The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Warfarin. Glimepiride. Amlodipine. (NSAIDs) can amplify the effects of anticoagulants; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral antidiabetic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided. 71. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? Preventing and recognizing hyperglycemia. 72. The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? 2000 mm3 73. A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? Draw a sample for PT and INR 74. The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient- controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? Attempt to arouse the client. 75. An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? Iron deficiency anemia 76. A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results? Place normal report in the clients medical record. Nutrition 77. The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? Oranges and dark green leafy vegetables 78. SATA The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Margarine. Cream cheese. Luncheon meats. 79. The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? Cream of wheat, blueberries, coffee. 80. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? Vitamin B12 81. A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? Summer squash 82. SATA A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Broth. Coffee. Gelatin. 83. The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? Smoked salami 84. A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet. The nurse should offer which full liquid item to the client? Custard 85. A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? Oranges 86. The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? Legumes 87. SATA The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Raisins. Potatoes. Cantaloupe. Strawberries. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. 88. SATA The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Peas. Nuts. Cauliflower. H/P Assessment of the adult client 89. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take? Page an interpreter from the hospital's interpreter services. 90. The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed. 91. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? Rhythmic respirations with periods of apnea 92. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A physical obstruction to the transmission of sound waves. 93. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? Gentle blowing or swooshing noise 94. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? Testing the 6 cardinal positions of gaze 95. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? After a shower or bath. 96. The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 97. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? Wheezes. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. 98. SATA The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Auscultating lung sounds. Obtaining the client's temperature. Obtaining information about the client's respirations. Provision of a Safe Environment 99. The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action? Contacting the maintenance department for assistance 100. The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? Safely securing the safety device straps to the side rails. 101. SATA The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Inhalation of bacterial spores. Through a cute or abrasion in the skin. Ingestion of contaminated undercooked meat 102. The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? Every 30 mins 103. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? Placing the client in a semiprivate room at the end of the hallway 104. Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? Gloves, gown, goggles and a mask or face shield 105. The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? Activate the fire alarm 106. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? Call the poison control center 107. The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? Activate the emergency response plan specific to the facility 108. The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? Private room or cohort client 109. The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? Isolate the client in a private room Preoperative Care 110. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? Urine output of 20 mL/hr 111. The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? "Use of an incentive spirometer will help prevent pneumonia." 112. The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Have the client void immediately before going into surgery. 113. A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? Obtain a telephone consent from a family member, following agency policy. 114. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? "Can you share with me what you've been told about your surgery?" 115. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. 116. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? "I need to continue to take the aspirin until the day of surgery.” 117. The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? Serous drainage 118. The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? Increasing restlessness 119. SATA A client who has had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken. 120. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? Hemoglobin, 8.0 g/dL (80 mmol/L) 121. The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? Assess the patency of the airway. 122. The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? Prednisone Positioning Clients 123. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? Lying in bed on the unaffected side 124. SATA The nurse is caring for a client following a craniotomy, in which a large cancerous tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the figures in options 1 to 4. Clients who have undergone craniotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. 125. The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? Bed rest with elevation of the affected extremity 126. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? On the nonoperative side with the legs abducted 127. The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? "I should sleep on my left side." 128. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? Left Sims' position 129. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? Supine, with the residual limb supported with pillows 130. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? Elevate and immobilize the grafted extremity 131. The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure? Bed rest with head elevation no greater than 30 degrees 132. The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? High Fowler's UNIT IV G & D Across the Life Span Theories of Growth and Development 133. The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level? Punishment and reward 134. The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? Allow the newborn infant to signal a need 135. The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action should the nurse take? Report the observation to the pediatrician 136. A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to the anal stage? This stage is associated with toilet training 137. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? The child has the ability to think abstractly 138. SATA The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Moral development progresses in relationship to cognitive development. A person's ability to make moral judgments develops over a period of time. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned. 139. SATA A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Set limits on the child's behavior. Provide a simple explanation of why the behavior is unacceptable. 140. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response. “At this age, the child is developing his own personality” Growth Development and Stages of Life 141. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? Encourage the child's parents to stay with the child. 142. A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? Allow the client to interact with others in his or her (adolescent) same age group. 143. Which car safety device should be used for a child who is 8 years old and 4 feet tall? Booster seat 144. The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate? Document the findings. 145. The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? Document the findings. 146. The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? Uses cup to drink 147. A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? "We will be sure not to leave hot liquids unattended." 148. A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? Inform the child of bedtime a few minutes before it is time for bed. 149. The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? Allow the bottle if it contains water. 150. The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? Crayons and coloring book. 151. The mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? A wagon 152. SATA Which interventions are appropriate for the care of an infant? Provide swaddling. Hang mobiles with black and white contrast designs. Caress the infant while bathing or during diaper changes. 153. SATA The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Encourage expression of feelings, concerns, and fears. Touch and hold the clients or family members hand if appropriate. Be honest and let the client and family know they will not be abandoned by the nurse 154. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? Apply cold pack at injection site. 155. A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? DTaP, Hib, IPV, PCV, and RV are administered at 4 months of age. 156. SATA The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Previous anaphylactic reaction to vaccine. Disorder that caused a severely deficient immune disorder. Care of an Older Client 157. The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age- related body changes, could place the client at risk for which complication with medication therapy? Increased risk for digoxin toxicity 158. The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? Allowing the client to choose social activities 159. SATA The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Looking at old snapshots of family. Participating at senior citizens program. Visiting spouses grave once a month. Decorating a wall with the spouses pictures and awards received. 160. The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What should the nurse tell the AP about older clients with hearing loss? They respond to low pitched tones 161. The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? “I drink hot chocolate before bedtime” 162. The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, “I'm in everyone's way; my daughter- in-law needs me to stay here.” Which is the most important action for the nurse to take? Suggest appropriate resources to the client and daughter in law such as respite care and a senior citizens center 163. The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? Determine whether there are medication duplicates 164. SATA The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Decline in visual acuity. Increased in susceptibility to urinary tract infections. Increased incidence of awakening after sleep onset. UNIT V Maternity Nursing Reproductive System 165. SATA The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? "The ductus arteriosus allows blood to bypass the fetal lungs." "One vein carries oxygenated blood from the placenta to the fetus." "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 166. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? "It connects the umbilical vein to the inferior vena cava." 167. A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? The appearance of the fetal external genitalia 168. The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? Notify the OB. 169. The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 170. SATA The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Allows for fetal movement. Surrounds, cushions, and protects the fetus. Maintains the body temperature of the fetus. Can be used to measure fetal kidney function 171. A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? "Do you plan to have any other children?" 172. The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? "Your type of pelvis is the most favorable for labor and birth." 173. SATA Which purposes of placental functioning should the nurse include in a prenatal class? It is the way the baby gets food and oxygen. It provides an exchange of nutrients and waste products between the mother and developing fetus. 174. A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? “Please share with me more about your concerns” Prenatal Period 175. The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? An informed consent needs to be signed before the procedure. 176. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? "The vaginal discharge may be bothersome but is a normal occurrence." 177. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? A normal test result 178. SATA A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Pregnancy needs to be avoided for 1 to 3 months. The vaccine is administered by the subcutaneous route. Exposure to immunosuppressed individuals needs to be avoided. A hypersensitivity reaction can occur if the client has an allergy to eggs. 179. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? "I need to lie flat on my back to perform the procedure." 180. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? The client is measuring normal for gestational age. 181. SATA The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy. Ballottement. Chadwick’s signs. Uterine enlargement. Positive pregnancy test. 182. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? Inform the client that these contractions are common and may occur throughout the pregnancy. 183. A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? July 26, 2019 Risk and Conditions Related to Pregnancy 184. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? "You will need to bottle-feed your newborn." 185. The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? The client complains of a headache and blurred vision. 186. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? "What can I do for you?" 187. The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? "I should avoid exercise because of the negative effects on insulin production." 188. The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? Evidence of bleeding, such as in the gums, petechiae, and purpura 189. SATA The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension. A gravida II who has just been diagnosed with dead fetus syndrome. A primigravida with abruption of placenta. 190. SATA The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Proteinuria. Hypertension. 191. The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? "I will need to increase my insulin dosage during the first 3 months of pregnancy." 192. A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? Isoniazid plus rifampin will be required for 9 months. 193. The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? "I should drink adequate fluids and increase my intake of high-fiber foods." 194. SATA The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? The client has a history of intravenous drug use. The client has a history of sexually transmitted infections. 195. The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? "We want to attend a support group." 196. The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. 197. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? "I will maintain strict bed rest throughout the remainder of the pregnancy." 198. SATA The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Routine administration of subcutaneous heparin may be prescribed. An overbed lift may be necessary if the client requires a cesarean section. Thromboembolism stockings or sequential compression devices may be prescribed. 199. SATA The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? The spontaneous urge to push is initiated from perineal pressure. The cervix is dilated completely. 200. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? Administer oxygen via face mask. 201. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? Uterine tenderness 202. The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? Obtain Equipment for manual pelvic examination 203. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? Delivery of fetus. 204. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? Hemorrhage 205. SATA The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Bright and red vaginal bleeding. Soft, relaxed, nontender uterus. Fundal height may be greater than expected for gestational age. [Show More]

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