Comprehensive Exam
55 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that place
...
Comprehensive Exam
55 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred?
A. A discoid uterus
B. Sudden sharp vaginal pain
C. Shortening of the umbilical cord
D. A sudden gush of dark blood from the introitus
56 A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?
A. The client reports a history of sexual abuse by her father.
B. The client reports that her relationship with her spouse is stable.
C. The client reports a satisfying intimate relationship with her spouse.
D. The client reports that her and her spouse have never been able to conceive children
57 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?
A. "I can resume sexual activity in 4 to 6 weeks."
B. "I need to avoid straining when I have a bowel movement."
C. "I should wear support hose for 6 months and elevate my legs frequently."
D. "I need to contact my surgeon immediately if I feel any numbness in my genital area."
58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.
A. Skin tenting
B. Flat neck veins
C. Weak peripheral pulses
D. Moist oral mucous membranes
E. A heart rate of 88 beats/min
F. A respiratory rate of 18 breaths/min
59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided.
Answer mL
Responses: "350"
60 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:
A. Salt substitutes
B. Herbs and spices
C. Salt with cooking only
D. Processed foods as desired
61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions?
A. Coffee
B. Broccoli
C. Cheeseburger
D. Chocolate milk
62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?
A. Headache
B. Drowsiness
C. Photophobia
D. Urinary frequency
63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client?
A. Diarrhea
B. Vomiting
C. Epistaxis
D. Epigastric pain
64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?
A. Count the number of times that the infant swallows during a feeding
B. Weigh the infant every day and check for a daily weight gain of 2 oz
C. Count wet diapers to be sure that the infant is having at least six to 10 each day
D. Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant
65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?
A. "My child will need to do exercises."
B. "My child needs to wear the brace 18 to 23 hours per day."
C. "Wearing the brace is really important in curing the scoliosis."
D. "I need to check my child's skin under the brace to be sure it doesn't break down."
66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with:
A. Milk
B. Water
C. Any meal
D. Tomato juice
67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:
A. Increase
B. Decrease
C. Remain unchanged
D. Double from what they normally are
68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:
A. No edema is present
B. The client is dehydrated
C. Pitting edema is present
D. Blood is not pooling in the extremities
69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:
A. Contact the physician
B. Document the findings
C. Ask the client to walk for 5 minutes, then recheck the reflexes
D. Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the reflexes
70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?
A. Hysterectomy
B. Insertion of an indwelling catheter
C. Administration of oxytocin (Pitocin)
D. Replacement of the uterus through the vagina into a normal position
71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:
A. Notify the physician
B. Recheck the temperature in 4 hours
C. Encourage the client to breastfeed the newborn
D. Institute strict bedrest for the client and notify the physician
72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be:
A. Documenting the findings
B. Encouraging the woman to walk
C. Helping the woman empty her bladder
D. Massaging the fundus gently until it becomes firm
73-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?
A. Anxiety
B. Premature grief
C. Fluid volume loss
D. Fluid volume overload
74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?
A. Increased platelet count
B. Shortened prothrombin time
C. Positive result on d-dimer study
D. Decreased fibrin-degradation products
75 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.
A. Tachycardia
B. Cool, clammy skin
C. Decreased respiratory rate
D. Diminished peripheral pulses
E. Urine output of less than 30 mL/hr
76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock?
A. Checking the client’s urine output
B. Inserting an intravenous (IV) line
C. Obtaining informed consent for a cesarean delivery
D. Placing the client in a lateral position with the bed flat
77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician?
A. Pink lochia on postpartum day 4
B. White lochia on postpartum day 11
C. Bloody lochia on postpartum day 2
D. Reddish lochia on postpartum day 8
78 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:
A. Document the findings
B. Ask the physician to see the client immediately
C. Ask another nurse to check for the uterine fundus
D. Place the client in the supine position for 5 minutes, then recheck the abdomen
79- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?
A. "Many of my antibodies are passed through the placenta."
B. "The placenta maintains the body temperature of my baby."
C. "Glucose, vitamins, and electrolytes pass through the placenta."
D. "It provides an exchange of oxygen and carbon dioxide between me and my baby."
80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is:
A. June 2, 2013
B. July 2, 2013
C. October 2, 2013
D. September 18, 2013
81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication?
A. Steak
B. Spinach
C. Chicken
D. Oranges
82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?
A. Sodium 140 mEq/L
B. Hemoglobin 12.5 g/dL
C. Blood urea nitrogen (BUN) 20 mg/dL
D. White blood cell count of 2500 cells/mm3
83 -Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse?
A. Nulliparity
B. Early menarche
C. Multiple sexual partners
D. Hormone-replacement therapy
84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding?
A. Umbilical cord compression
B. Pressure on the fetal head during a contraction
C. Uteroplacental insufficiency during a contraction
D. Inadequate pacemaker activity of the fetal heart
85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
A. At any time after the surgery
B. When menstruation resumes
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