A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2 hours ago. She is having mild contractions 5 minutes apart.
QUESTION 601A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2 hours ago. She is having mild contractions 5 minutes apart.
The most immediate nursing intervention would be to:
A. Note the color and amount of fluid on her clothes.
B. Assess the FHR.
C. Notify the physician.
D. Place the nitrazine test paper at the cervical os and note the color change.
QUESTION 602A 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. “Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract.”
B. “Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement.”
C. “The same hormone that is released in response to the baby’s sucking, causing milk to flow, also causes the uterus to contract.”
D. “There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it.”
QUESTION 603A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, “Why did this happen to my
baby?” is:
A. “It’s God’s will. It was probably for the best. There was something probably wrong with your baby.”
B. “You’re young. You can have other children later.”
C. “I know your other children will be a great comfort to you.”
D. “I can see you’re upset. Would you like to see and hold your baby?”
QUESTION 604A 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. In the immediate postpartum period
B. After the first trimester
C. At 28 weeks’ gestation
D. Within 72 hours postpartum
QUESTION 605A 24-year-old woman who is gravida 1 reports, “I can’t take iron pills because they make me sick.” She continues, “My bowels aren’t moving either.” In counseling
her based on these complaints, the nurse’s most appropriate response would be, “It would be beneficial for you to eat . . .
A. prunes.”
B. green leafy vegetables.”
C. red meat.”
D. eggs.”
QUESTION 606A 26-year-old female client presents at 10 weeks’ gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also
has insulin-dependent diabetes. The client’s previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is
130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
A. Age>25 years
B. Maternal weight
C. Previous birth of an infant weighing>9 lb
D. Family history of heart disease
QUESTION 607The nurse assesses a client’s monitor strip and finds the following: uterine contractions every 3 4 minutes, lasting 6070 seconds; FHR baseline 134146 bpm, with
accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
A. Notify physician of nonreassuring FHR pattern.
B. Turn the client to her left side.
C. Start IV for fetal distress and administer O2 at 68 liters by mask.
D. Evaluate to see if the monitor strip is reassuring.
QUESTION 608Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the
importance of:
A. Decreasing her sodium intake
B. Decreasing her fluids
C. Increasing her carbohydrate intake
D. Eating a moderate to high-protein diet
QUESTION 609A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and
epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
A. “It sounds as though you are coming down with a bad cold. I’ll ask the doctor to prescribe a decongestant for relief of symptoms.”
B. “A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.”
C. “These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.”
D. “This is most unusual. I’m sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.”
QUESTION 610A newborn girl’s father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain
neurological patterns that characterize the newborn:
A. Mild hypotonia is expected in the upper extremities.
B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.
C. Function progresses in a head-to-toe, proximal-distal fashion.
D. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system.
QUESTION 611A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing
response is to:
A. Administer methergine IM
B. Remove the retained placental fragments
C. Assist the client to the bathroom and provide cues to stimulate urination
D. Massage the fundus until firm
QUESTION 612A 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:
A. Chadwick’s sign
B. FHR by ultrasound
C. Enlargement of the uterus
D. Breast tenderness and enlargement
QUESTION 613A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:
A. Sulfa
B. Tetracycline
C. Hydralazine
D. Erythromycin
QUESTION 614A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
A. Sitting with legs crossed at ankles
B. Wearing thromboembolic disease (TED) stockings
C. Wearing support pantyhose
D. Wearing knee-high stockings
QUESTION 615A client at 9 weeks’ gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a
spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the
following:
A. An increased risk in maternal adaptation to pregnancy
B. The need for anticipatory guidance regarding the pregnancy
C. The need for teaching regarding family planning
D. An increased risk for subsequent abortions
QUESTION 616A client is pleased about being pregnant, yet states, “It is really not the best time, but I guess it will be OK.” The nurse’s assessment of this response is:
A. Initial maternal-infant bonding may be poor.
B. Client may have a poor relationship with her husband.
C. This response is normal in the first trimester.
D. This response is abnormal, to be re-evaluated at the next visit.
QUESTION 617A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is
assessed as sufficient. The most likely diagnosis is:
A. Iron-deficiency anemia
B. Physiological anemia
C. Fatigue due to stress
D. No problem indicated
QUESTION 618In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal
that should be reported immediately?
A. Backache
B. Leaking of clear yellow fluid from breasts
C. Constipation with hemorrhoids
D. Visual changes
QUESTION 619The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold’s maneuvers by having her:
A. Empty her bladder
B. Lie on her left side
C. Place her arms over her head
D. Force fluids 1 hour prior to procedure
QUESTION 620Before giving methergine postpartum, the nurse should assess the client for:
A. Decreased amount of lochial flow
B. Elevated blood pressure
C. Flushing
D. Afterpains
QUESTION 621A 24-hours’ postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To
relieve the discomfort, the nurse should first:
A. Assist her with a sitz bath
B. Administer the prescribed medication for pain
C. Teach her Kegel exercises
D. Apply an ice pack
QUESTION 622The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed
to:
A. Wear gloves for the procedure
B. Place and adjust the pad from back to front
C. Cleanse and wipe the perineum from front to back
D. Protect the outer surface of the pad from contamination
QUESTION 623In teaching the client about proper umbilical cord care, the nurse recommends that:
A. Petrolatum be placed around the cord after the sponge bath
B. A belly binder be applied to prevent umbilical hernia
C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
D. The cord clamp be left on until the cord stump separates
QUESTION 624A baby is circumcised. Immediate postoperative care should include:
A. Applying a loose diaper
B. Keeping the baby NPO for 4 hours to avoid vomiting
C. Changing the dressing frequently using dry, sterile gauze
D. Taking the baby to his mother for cuddling
QUESTION 625A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks’ gestation, all of the following observations are made. Which would require
intervention?
A. Weight gain of 2 kg in 4 weeks
B. Blood pressure of 128/78
C. Subjective data: shortness of breath after showering
D. Ankle edema reported present in late afternoon and evenings
QUESTION 626A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the
physician?
A. Contractions every 2 minutes, lasting 100 seconds
B. Fetal heart decelerations during a contraction
C. Beat-to-beat variability between contractions
D. Fetal heart decelerations at the beginning of contractions
QUESTION 627A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is
complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
A. Place her in knee-chest position during the contraction
B. Use effleurage during the contraction
C. Apply strong sacral pressure during the contraction
D. Have her push with each contraction
QUESTION 628The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine
oxidase (MAO) inhibitor. Which of the following is she restricting from the client’s diet?
A. Cream cheese
B. Fresh fruits
C. Aged cheese
D. Yeast bread
QUESTION 629A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse
reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this
conclusion?
A. High fever, tachycardia, stupor, renal failure
B. Lip smacking, chewing, blinking, lateral jaw movements
C. Photosensitivity, orthostatic hypotension, dry mouth
D. Constipation, blurred vision, drowsiness
QUESTION 630On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand
tremor. Which one of the following nursing actions is essential at this time?
A. Administer her next dosage of lithium, and then call the physician.
B. Withhold her lithium, and report her symptoms to the physician.
C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
QUESTION 631In acute episodes of mania, lithium is effective in 12 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an
antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In
addition to the lithium, which one of the following medications might the physician prescribe?
QUESTION 631
In acute episodes of mania, lithium is effective in 12 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an
antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In
addition to the lithium, which one of the following medications might the physician prescribe?
A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam (Xanax)
QUESTION 632The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social,
or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following
conditions?
A. Dementia
B. Parkinsonism
C. Delirium
D. Mania
QUESTION 633A 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?
A. Always allow the most vocal person to state the problem first.
B. Encourage the mother to speak for the children.
C. Interpret immediately what seems to be going on within the family.
D. Allow family members to assume the seats as they choose.
QUESTION 634In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions
might be a primary prevention strategy?
A. Crisis intervention with an intoxicated teenager whose mother just committed suicide
B. Referring a client who has been on a detoxification unit to a rehabilitation center
C. Teaching fifth-grade children the harmful effects of substance abuse
D. Counseling a client with post-traumatic stress disorder
QUESTION 635While the nurse is taking a male client’s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
A. Politely tells the client, “Keep your hands off “
B. Ignores the remarks and hopes he will not try it again
C. Confronts the remarks but attempts not to reject the client
D. Leaves the room in order to compose herself
QUESTION 636A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she
has been experiencing in her relationship with her husband of 5 years. In the “tension-building phase,” the nurse might expect the client to describe which of the
following?
A. Promises of gifts that her husband made to her
B. Acute battering of the client, characterized by his volatile discharge of tension
C. Minor battering incidents, such as the throwing of food or dishes at her
D. A period of tenderness between the couple
QUESTION 637Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
A. Fine hand tremor, headache, mental dullness
B. Vomiting, impaired consciousness, decreased blood pressure
C. Polyuria, polydipsia, edema
D. Gastric irritation, nausea, diarrhea
QUESTION 638A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is
important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
A. Antipsychotic medications
B. Antidepressant medications
C. Antianxiety medications
D. Antimania medication
QUESTION 639The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the
nurse knows that the client is effectively coping with the rape when she tells the nurse:
A. “I know it was my fault that it happened, because I shouldn’t have been out so late.”
B. “If I had not worn that sexy dress that night, he wouldn’t have raped me.”
C. “I know my date just had so much passion he couldn’t handle me saying `no.’ “
D. “I know now that it was not my fault, but I want to continue counseling after my discharge.”
QUESTION 640A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is
preparing for discharge and is effectively coping with his problem when he shares with her the following information:
A. “I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group.”
B. “I know that I can only drink one or two drinks at social gatherings in the future, but at least I don’t have to continue AA.”
C. “I really wasn’t addicted to alcohol when I came here, I just needed some help dealing with my divorce.”
D. “It really wasn’t my fault that I had to come here. If my wife hadn’t left, I wouldn’t have needed those drinks.”
QUESTION 641Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions
occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?
A. “Some folks believe that aging causes this, Mother.”
B. “Perhaps, it’s the way your parents used those double- bind messages, Mother.”
C. “I know some people who are having this problem and they were exposed to chemicals at work, Mother.”
D. “It can be caused by lots of things, toxic agents and even alcohol, Mother.”
QUESTION 642A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their
marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for
the nurse to remember which of the following principles?
A. The parts of a system are only minimally related.
B. Dysfunction in one part affects every other part.
C. A family system has no boundaries.
D. Healthy families are enmeshed.
QUESTION 643The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is
experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son’s condition by which of
the following statements?
A. “Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain.”
B. “Has anyone in your family ever had schizophrenia?”
C. “If your son has a twin, he probably will eventually develop schizophrenia, too.”
D. “Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship.”
QUESTION 644A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after
she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse’s most therapeutic response will be:
A. “I don’t see your mother in the room. Let’s talk about how you’re feeling.”
B. “OK, I’ll come back later when you’re feeling more like taking your medicine.”
C. “She may be here, but I can’t see her.”
D. “Why don’t you finish talking to her, and I’ll wait.”
QUESTION 645A female client with major depression stated that “life is hopeless and not worth living.” The nurse should place highest priority on which of the following questions?
A. “How has your appetite been recently?”
B. “Have you thought about hurting yourself?”
C. “How is your relationship with your husband?”
D. “How has your depression affected your daily livingactivities?”
QUESTION 646A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating,
repeated absences from work due to “fatigue,” and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost
interest in answering the phone or doorbell. The nurse’s assessment of her behavior would most likely be:
A. Deep depression
B. Psychotic depression
C. Severe anxiety
D. Severe depression
QUESTION 647A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20- year history of alcohol abuse. The client is diagnosed with cirrhosis.
His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?
A. Lifting heavy objects
B. Walking briskly
C. Ingestion of barbiturates
D. Ingestion of antacids
QUESTION 648Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
A. Vitamin C and zinc
B. Folic acid and niacin
C. Vitamin A and biotin
D. Thiamine and pyroxidine
QUESTION 649The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client’s best choice from the items below
would be:
A. Liver and onions, macaroni and cheese, tea with sugar
B. Baked chicken, baked potato with bacon bits, milk
C. Waffles with butter and honey, orange juice
D. Cheese omelette with ham and mushrooms, milk
QUESTION 650A chronic alcoholic client’s condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic
coma?
A. Hiccups
B. Anorexia
C. Mental confusion
D. Fetor hepaticus
QUESTION 651The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by:
A. Decreasing nitrogen-forming bacteria in the intestines
B. Acidifying colon contents by causing ammonia retention in the colon
C. Decreasing the uptake of vitamin D, thereby drawing more water into the colon
D. Irritating the bowel and promoting evacuation of stool
QUESTION 652A 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. D50W by IV push
B. NPH insulin SC
C. Regular insulin by IV infusion
D. Sweetened grape juice by mouth
QUESTION 653A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely
for serum:
A. Chloride level of 99 mEq/L
B. Sodium level of 136 mEq/L
C. Potassium level of 3.1 mEq/L
D. Potassium level of 6.3 mEq/L
QUESTION 654An 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:
A. 8:30 AM10:30 AM
B. 2:30 PM4:30 PM
C. 7:30 PM9:30 PM
D. 10:30 PM11:30 PM
QUESTION 655After several days, an IDDM client’s serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps
him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:
A. One frankfurter
B. One ounce of ham
C. Two slices of bacon
D. One-fourth cup dry cottage cheese
QUESTION 656When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:
A. When exercise is increased, insulin needs are increased
B. When exercise is increased, insulin needs are decreased
C. When exercise is increased, there is no change in insulin needs
D. When exercise is decreased, insulin needs are decreased
QUESTION 657A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled
to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may
accompany BPH is:
A. Acute urinary retention
B. Hesitancy in starting urination
C. Increased frequency of urination
D. Decreased force of the urinary stream
QUESTION 658A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress.
The purpose of this bladder irrigation is to prevent:
A. Bladder spasms
B. Clot formation
C. Scrotal edema
D. Prostatic infection
QUESTION 659Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client’s sexual functioning?
A. “You may resume sexual intercourse in 2 weeks.”
B. “Many men experience impotence following TURP.”
C. “A transurethral resection does not usually cause impotence.”
D. “Check with your doctor about resuming sexual activity.”
.QUESTION 660A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this
situation to be:
A. Determination of multiple gestations
B. Determination of gross anomalies
C. Determination of placental location
D. Determination of fetal age
QUESTION 661A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
A. Thready pulse
B. Irregular pulse
C. Tachycardia
D. Bradycardia
QUESTION 662A client is being admitted to the labor and delivery unit. She has had previous admissions for “false labor.” Which clinical manifestation would be most indicative of
true labor?
A. Increased bloody show
B. Progressive dilatation and effacement of the cervix
C. Uterine contractions
D. Decreased discomfort with ambulation
QUESTION 663In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
A. A 31 patellar tendon reflex
B. Respirations of 12 breaths/min
C. Urine output of 40 mL/hr
D. A 21 proteinuria value
QUESTION 664A 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:
A. Lung immaturity
B. Intrauterine growth retardation (IUGR)
C. Intrauterine infection
D. Neural tube defect
QUESTION 665On admission to the postpartal unit, the nurse’s assessment identifies the client’s fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right.
This is most likely an indication of:
A. Normal involution
B. A full bladder
C. An infection pain
D. A hemorrhage
QUESTION 666A client’s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
A. Assess quantity of fluid.
B. Assess color and odor of fluid.
C. Document on fetal monitor strip and chart.
D. Assess fetal heart rate (FHR).
QUESTION 667The 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:
A. A low birth weight
B. A birth defect
C. Anemia
D. Nicotine withdrawal
QUESTION 668Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A. Hemoglobin 17.2 g/dL
B. Platelets 250,000/mm3
C. Serum glucose 30 mg/dL
D. White blood cells 18,000/mm3
QUESTION 669A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2
years. The highest priority intervention at this time is to:
A. Assess level of consciousness
B. Assess suicide potential
C. Observe for sedation and hypotension
D. Orient to her room and unit rules
QUESTION 670A client’s record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most
appropriate at this time?
A. High carbohydrate, low cholesterol
B. High protein, high carbohydrate
C. 1 g sodium
D. Tyramine-free
QUESTION 671Two weeks after a client’s admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if
present, would be a contraindication for ECT?
A. Brain tumor or other space-occupying lesion
B. History of mitral valve prolapse
C. Surgically repaired herniated lumbar disk
D. History of frequent urinary tract infections
QUESTION 672A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period. Her husband asks, “Isn’t that a lot?” The nurse’s best
response is:
A. “Yes, that does seem like a lot.”
B. “You’ll have to talk to the doctor about that. The physician knows what’s best for the client.”
C. “Six to 10 treatments are common. Are you concerned about permanent effects?”
D. “Don’t worry. Some clients have lots more than that.”
QUESTION 673A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is:
A. “You’ll have to get permission from the physician to visit. Clients are pretty sick after the first treatment.”
B. “Visitors are not allowed. We will telephone you to inform you of her progress.”
C. “There’s really no need to stay with her. She’s going to sleep for several hours after the treatment.”
D. “Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment.”
QUESTION 674A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his
behavior is more subdued, but he tells the nurse, “The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room,
he’s going to cut out my heart.” The nurse’s best response is:
A. “I know you’re feeling frightened right now, but I want you to know that I don’t see anyone in the corner.”
B. “You’ll probably see strange things for a while until the PCP wears off.”
C. “Try to sleep. When you wake up, the devil will be gone.”
D. “You’re probably feeling guilty because you used illegal drugs tonight.”
QUESTION 675A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for client to exercise.
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