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A client is 6 weeks pregnant. During her first prenatal visit, she asks, “How much alcohol is safe to drink during pregnancy?” The nurse’s response is:
As soon as a child has been diagnosed as “hearing impaired,” special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, “It’s not so easy for me to just go right to the hospital like that.” After acknowledging her feelings, which of these approaches by the nurse would probably be best?
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:
The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?
A physician’s order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.
What dosage should the nurse administer to the infant?
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24–48 hours postburn?
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:
The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:
The physician orders medication for a client’s unpleasant side effects from the haloperidol. The most appropriate drug at this time is:
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele’s rule, the nurse estimates her date of delivery to be:
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 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
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 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 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 client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client’s vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse’s understanding of normal fluid requirements for this infant?
Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother’s discharge teaching plan?
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 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant’s developmental progression?
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:
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client’s nursing assessment demand immediate nursing action?
A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, “You leave me alone. You don’t care anything about me. It’s people like you who let my baby die.” The nurse’s best course of action is to:
A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:
A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:
Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:
When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4–8) of pregnancy is so critical.
A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care 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:
Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious and asks what she could have done to prevent the exacerbation. The nurse’s response is based on the knowledge that chronic osteomyelitis:
Cheyne-Stokes respiratory pattern can be associated with which of the following conditions?
The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:
A client’s behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:
A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse’s notes indicated that the client admitted to “having a few drinks now and then.” He is probably experiencing which of the following?
A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with trivial details and schedules. A nursing intervention appropriate for this client would include:
A mother called the physician’s office to ask if it would help relieve her small daughter’s abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.
The nurse’s response is based on the knowledge that:
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:
Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually:
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is:
Discharge teaching for the client who has a total gastrectomy should include which of the following?
The nurse is teaching a child’s parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis—Alteration in comfort, pain related to:
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking “the blue pill” (haloperidol) in the morning and evening, and “the white pill” (benztropine) right before bedtime. The nurse might suggest to the client that she try:
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 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client’s:
Goal setting for a client with Meniere’s disease should include which of the following?
A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?
Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
At 38 weeks’ gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:
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:
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?
What is the appropriate nursing action for a child with increased intracranial pressure?
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should the RN question?
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:
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 client’s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:
A first-trimester primigravida is diagnosed with anemia.
The nurse should suspect that this anemia is a result of:
A physician’s order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
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:
A client is diagnosed with organic brain disorder. The nursing care should include:
A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, “Something is wrong. This is like my labor.” Which reply by the nurse identifies the physiological response of the client?
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:
A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?
A client’s prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
An IDDM client’s condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at:
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?
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:
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
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:
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:
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 couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:
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?
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client’s obstetrical history, the nurse should record:
A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?
In cleansing the perineal area around the site of catheter insertion, the nurse would:
After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse’s appropriate response is:
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate
(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, “Oh dear, I feel like I have to urinate again!” Which of the following is the most appropriate initial nursing response?
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?
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:
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:
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, “I just couldn’t take it anymore.” The nurse’s best response to this disclosure would be:
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
During burn therapy, morphine is primarily administered IV for pain management because this route:
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:
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
TESTED 04 May 2024