Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?
Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?
A. Heterozygotes are affected.
B. The disorder is always carried on the X chromosome.
C. Only females are affected.
D. Two affected parents always have affected children.
“
QUESTION 452
Prior to an amniocentesis, a fetal ultrasound is done in order to:
A. Evaluate fetal lung maturity
B. Evaluate the amount of amniotic fluid
C. Locate the position of the placenta and fetus
D. Ensure that the fetus is mature enough to perform the amniocentesis
.QUESTION 453
An expected response to sodium polystyrene sulfonate (Kayexalate) is:
A. Increase in serum magnesium
B. Increase in serum HCO3
C. Decrease in serum potassium
D. Decrease in serum calcium
QUESTION 454
A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:
A. Discuss the disease process and the importance of the medication in prevention of symptoms.
B. Inform the client that additional side effects are to be expected and need not be reported.
C. Discuss the importance of getting blood drawn weekly to determine medication therapeutics.
D. Inform the client to cease taking the medication when all psychotic symptoms have cleared.
QUESTION 455
A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse observes her walking with a shuffling gait and postural rigidity and notes a masklike expression on her face. Which side effect is this client exhibiting?
Dystonia
Parkinsonism
Tardive dyskinesia
Akathesia
.
QUESTION 456
A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:
A. “I know that I am not supposed to irrigate my colostomy.” B. “My stool will be soft like paste.”
C. “My stoma should be red and slightly raised.”
D. “The skin around my stoma may become irritated from the enzymes in my stool.”
QUESTION 457
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. Encouraging him to engage in recreational activities
B. Avoiding discussion of his annoying behavior
C. Encouraging the client to set a time schedule and deadlines for himself
D. Contracting with him for the amount of time he will spend on the compulsive behaviors
QUESTION 458
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
Exudate
Crust
Edema
Erythema
QUESTION 459
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
A. A left hemothorax
B. A right hemothorax
C. Intubation of the right mainstem bronchus
D. An inadequate mechanical ventilator
QUESTION 460
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
A. Providing him with books, challenging puzzles, and games as diversionary activities
B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision C. Having a volunteer come in to sit with the client and to read him stories
D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client’s position frequently
.QUESTION 461
A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:
A. Doing crafts in occupational therapy
B. Working a 1000-piece puzzle
C. Playing bridge with three other clients
D. Playing basketball in the gym
QUESTION 462
A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?
A. Whole blood
Platelets
Fresh frozen plasma
Packed red blood cells
QUESTION 463
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
A. Hyperextension of the neck with evidence of pain on flexion
B. Holding the head to one side and pointing the chin toward the other side
C. Holding the head erect and in the midline when in a vertical position
D. Significant head lag when raised to a sitting position
QUESTION 464
The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client. The nurse instructs the client that B6 is given because it:
A. Increases activity of isoniazid
B. Increases activity of rifampin
C. Improves nutritional status
D. Reduces peripheral neuropathy
QUESTION 465
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
A. Taping a pouch that is leaking
B. Cutting the skin barrier 112 inches larger than the stoma
C. Changing the pouch only when leakage occurs
D. Using a skin sealant under pouch adhesives
QUESTION 466
In the coronary care unit, a client has developed multifocal premature ventricular contractions. The nurse should anticipate the administration of:
Furosemide
Nitroglycerin
Lidocaine
Digoxin
QUESTION 467
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia B. Catheterize the client and reassess the uterus
C. Begin IV fluids and administer oxytocic medication
D. Administer analgesics as ordered to relieve discomfort
QUESTION 468
When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?
Potassium
Magnesium
Sodium
HCO3
QUESTION 469
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2–3 more times to complete the series every 1–2 hours while awake
B. Purse the lips and take quick, short breaths approximately 18–20 times/min
C. Take a large gulp of air into the mouth, hold it for 10–15 seconds, and then expel it through the nose. Repeat 4–5 times to complete the series
D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20– 24 times/min
QUESTION 470
The client tells the nurse, “I have pain in my left shoulder.”
This is considered:
A. Evaluation process
B. Objective information
C. Subjective information
D. Complaining
QUESTION 471
A 10-month-old infant’s mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse’s response is based on the knowledge that:
A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices
B. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
D. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day
QUESTION 472
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
A. Flight of ideas
Delusions
Hallucinations
Echolalia
QUESTION 473
During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the child’s change in behavior?
A. Deep-seated feelings of hostility
B. A lack of interest in socializing
C. Usual behavior for this child
D. A coping response
QUESTION 474
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 dyspne
A. Which of the following findings in the client’s nursing assessment demand immediate nursing action?
A. Associated symptoms of indigestion and nausea
B. Restlessness and apprehensiveness
C. Inability to tolerate assessment session with the admitting nurse
D. History of hypertension treated with pharmacological therapy
.QUESTION 475
To facilitate maximum air exchange, the nurse should position the client in:
A. High Fowler
Orthopneic
Prone
Flat-supine
.
QUESTION 476
A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse’s knowledge of the central nervous system, the nurse knows that benign tumors:
“
A. Can be just as dangerous as malignant tumors
B. Grow more rapidly than malignant tumors
C. Do not warrant concern because they do not become malignant tumors
D. Can be removed surgically
.
QUESTION 477
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
A. Aplastic crisis
Vaso-occlusive crisis
Dactylitis crisis
Sequestration crisis
QUESTION 478
A client who has gout is most likely to form which type of renal calculi?
A. Struvite stones
B. Staghorn calculi
C. Uric acid stones
D. Calcium stones
QUESTION 479
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardi A. What first nursing actions would be essential in this situation?
A. Hold the child’s discharge for 1 hour.
B. Notify the physician immediately.
C. Discharge the child as the physician ordered.
D. Administer an antiemetic as necessary.
QUESTION 480
Nursing care for the parents of a child with a congenital heart defect would include:
A. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible
B. Acknowledging the fear and concern surrounding their child’s health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child
C. Identifying anger and resentment as destructive emotions that serve no purpose
D. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve
QUESTION 481
When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4–8) of pregnancy is so critical.
A. Duplication of genetic information takes place.
B. Organogenesis occurs.
C. Subcutaneous fat builds up steadily.
D. Kidneys begin to secrete urine.
QUESTION 482
Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
A. Cutting, pasting, string beads, music, dolls
B. Mobiles, rattle, squeeze toys
C. Pull-toys, large ball, dolls, sand and water play, music
D. Simple card games, puzzles, bicycle, television
QUESTION 483
A 5-year-old child was recently diagnosed as having acute lymphoid leukemi
A. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
A. Explain what will take place and what she will see, feel, and hear.
B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
“
QUESTION 484
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
A. 50–100 mL
B. 200–300 mL
C. 300–500 mL
D. 1000–1200 mL
QUESTION 485
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
B. Advise the client to discontinue the drug at the first sign of dizziness.
C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
D. Instruct the client in Valsalva’s maneuver to equalize middle ear pressure and to prevent hearing loss.
QUESTION 486
The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
A. Ringer’s lactate
B. D5 in water
C. D5 with Ringer’s lactate
D. Normal saline
QUESTION 487
A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states:
A. “If I drink 10 to 12 glasses of fluids each day, that will help to prevent any clot formation in my urine.”
B. “The isometric exercises will help to strengthen my perineal muscles and help me control my urine.”
C. “If I feel as though I have developed a fever, I will take a rectal temperature, which is the most accurate.”
D. “I do not plan to do any heavy lifting until I visit my doctor again.”
QUESTION 488
The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client’s urine output pattern as:
Anuria
Oliguria
Dysuria
Polyuria
.QUESTION 489
The most frequent cause of early postpartum hemorrhage is:
Hematoma
Coagulation disorders
C. Uterine atony
D. Retained placental fragments
QUESTION 490
A 42-year-old client presents with a diagnosis of paranoid schizophreni
A. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
Depression
Agitation
Psychotic ideation
Anhedonia
QUESTION 491
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
A. Activity intolerance
B. Ineffective airway clearance
C. High risk for infection
D. Altered oral mucous membrane
QUESTION 492
A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:
A. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened B. Marked engorgement and breast pain
C. Elevated temperature and general malaise
D. Cracked nipple with complaints of soreness
QUESTION 493
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
A. Take a baseline set of vital signs
B. Hang Ringer’s lactate as the companion fluid
C. Use microdrip tubing for the blood administration
D. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
QUESTION 494
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client’s pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:
A. Bright red with streaks
B. Rust colored
C. Green colored
D. Pink-tinged and frothy
QUESTION 495
A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat?
A. Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals B. A bland, moist, soft diet
C. Staying with the client and providing distraction during meals
D. Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before meals
QUESTION 496
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
Excoriation
Dehiscence
Decortication
Evisceration
QUESTION 497
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:
A. Respiratory obstruction
Hypercalcemia
Fistula formation
Myxedema
QUESTION 498
A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?
A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate.
B. Serum sodium is low. The nurse should change IV fluids to normal saline.
C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client’s diet as soon as possible.
D. Serum potassium is low. The nurse should administer KCl as ordered.
QUESTION 499
A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
A. Providing opportunities to ask questions and talk about concerns B. Providing distractors such as reading or watching television
C. Telling her that she should not be so nervous and assuring her that everything will be OK D. Reminding her that this surgery is not as extensive as her past surgery was
QUESTION 500
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first 24 hours after surgery and cast application?
A. Mobilization of the child
B. Discharge teaching
C. Pain management
D. Assessment of neurovascular status
QUESTION 501
When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:
A. 30 minutes
B. 1–4 hours
C. 12–24 hours
D. 24–72 hours
QUESTION 502
A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim- sulfamethoxazole (Bactrim) DS bid for 10 days. She
was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
A. “I have not been drinking six to eight glasses of water each day as the nurse had instructed.”
B. “I’m afraid I may have something wrong with my bladder because I have been getting bladder infections frequently since I’ve been married.”
C. “I took the Bactrim for 6 or 7 days. The burning stopped, so I saved the rest of the medication for the next time.”
D. “I recently had the flu, which could be settling in my kidneys now.”
QUESTION 503
Endotracheal tube cuff pressure should never exceed:
A. 10 mm Hg
B. 20 mm Hg
C. 45 mm Hg
D. 60 mm Hg
QUESTION 504
Primary nursing diagnoses for the antisocial client are:
A. Alteration in perception and altered self-concept
B. Impaired social interaction, ineffective individual coping, and altered self-concept
C. Altered communication processes and altered recreational patterns
D. Altered body image and altered thought processes
QUESTION 505
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
A. By inserting pins to provide steady pull on the bone
B. To suspend the leg in a sling without pull on the extremity
C. Intermittently to place a pull over the pelvis and lower spine
D. With weights at both ends of the bed to maintain pull on the upper extremity
QUESTION 506
In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
A. Explain the side effects of the medication
B. Discuss the danger of overmedication
C. Distribute written material to supplement verbal instructions
D. Explore the client’s perception regarding medication therapy
.
QUESTION 507
A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound
unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not
allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of
panic. The client has been diagnosed with agoraphobi
A. Which statement is true about this disorder?
A. The behavior is not considered disabling.
B. More men suffer from agoraphobia than women.
C. The fears are persistent, and avoidance is used as the coping mechanism.
D. Agoraphobia moves into remission when treated with chlorpromazine.
QUESTION 508
The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:
A. Month-old magazines that are provided by volunteers
B. Large maps and posters depicting area of current residence
C. A litter of kittens for the clients to pet
D. A library of biographical books
QUESTION 509
An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:
A. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose B. They need to mix it with formula so the infant swallows it easily
C. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the physician
D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed
QUESTION 510
A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse’s frequent monitoring of the child’s temperature frightened her parents. Which response by the nurse would be most appropriate?
A. Monitoring the temperature prevents undue chilling.
B. Rapid temperature elevations can occur in children.
C. Checking the temperature will prevent febrile seizures.
D. Taking the child’s temperature can prevent airway obstruction.
QUESTION 511
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
A. He should not be concerned about it because it will resolve quickly
B. This is usually temporary
C. The nurse will keep him dry, and he should notify the nurse when this happens
D. This is related to the bladder spasms and will soon stop
QUESTION 512
A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:
A. Have transient memory loss, confusion, andheadache
B. Be alert and oriented immediately after the treatment
C. Have insomnia for the first few days
D. Require no special care after the procedure
QUESTION 513
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
A. Prolonged bed rest
B. The client’s maintaining a semi-Fowler position
C. Cerebral hypoxia
D. IV fluids of 2.5–3 liters in 24 hours
.
QUESTION 514
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
A. Hypovolemic shock
Hypokalemia
Hypernatremia
Hyponatremia
QUESTION 515
On an assessment of a client’s mouth, the nurse notices white patches on the buccal mucos
A. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
Xerosteromia
Candidiasis
Leukoplakia
Stomatitis
QUESTION 516
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client’s return to her room, which nursing measure best demonstrates the nurse’s thorough understanding of possible postthyroidectomy complications?
A. Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.
B. Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.
C. A tracheostomy set, O2, and suction are available at the bedside.
D. The nurse should instruct the client as soon as possible on alternative means of communication.
QUESTION 517
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
A. Gravida 4, para 2, ab 1
B. Gravida 5, para 3, ab 1
C. Gravida 5, para 4, ab 0
D. Gravida 4, para 3, ab 0
.
QUESTION 518
A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?
A. Vitamin C
B. Vitamin K
C. Vitamin E
D. Vitamin A
QUESTION 519
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician
diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?
A. Reticulocyte count, creatinine phosphokinase (CPK)
B. Aspartate transaminase, alanine transaminase
C. Sedimentation rate, WBC count
D. Lactic dehydrogenase, CPK
QUESTION 520
A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate
further evaluation?
A. Complaints of a headache
B. Loss of superficial and deep tendon reflexes
C. Complaints of shortness of breath
D. Facial paralysis
QUESTION 521
Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?
Dysuria
Epistaxis, hematuria, dysuria
Vertigo, hematuria, ecchymosis
Hematuria, ecchymosis, and epistaxis
QUESTION 522
An obstructing stone in the renal pelvis or upper ureter causes:
A. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males B. Urinary frequency and dysuria
C. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor D. Dull, aching, back pain
QUESTION 523
A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?
A. “Do you get along well with your family?”
B. “Do you communicate with your parents?”
C. “You don’t hate your family, do you?”
D. “What is it like between you and your family?”
QUESTION 524
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
A. D5in normal saline
D5W
0.9 normal saline
D5in lactated Ringer’s
QUESTION 525
As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:
A. It may be a bid for attention and an indication that more diversionary activity should be planned for him B. No threat of suicide should be ignored or challenged in any way
C. He needs to be observed carefully for signs that his depression has been relieved
D. He needs to be confronted with his feelings and forced to work through them
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