Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
QUESTION 526Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
A. She uses the bulb syringe to help clear her baby’s nose when milk is regurgitated.
B. She places her infant on her right side after feeding her.
C. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.
D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
QUESTION 527Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:
A. Immediately after birth, because the most accurate result is obtained at this time
B. After 23 days of milk ingestion
C. At 23 days of age regardless of amount of milk feedings
D. At 1 month, because the biochemical buildup of phenylalanine takes 1 month to detect
QUESTION 528A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a
young child with symptoms of influenza, the mother must be cautioned about:
A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
B. Giving clear liquids too soon
C. Allowing the child to come in contact with other children for 3 days
D. The possibility of pneumonia as a complication
QUESTION 529A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client’s responses would indicate compliance during initial therapy?
A. Drinking large amounts of milk
B. Not bearing weight on affected extremity
C. Walking short distances 3 times/day
D. Putting self on weight reduction diet
QUESTION 530A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further
teaching?
A. “My daughter takes her aspirin with her meals.”
B. “Her gums have been bleeding frequently. Maybe she is brushing too hard.”
C. “I give her aspirin on a regular schedule every day.”
D. “One sign of aspirin toxicity can be ringing in the ears.”
QUESTION 531A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:
A. Prevention of neurovascular complications
B. Prevention of loss of muscle tone
C. Immobilization of the affected limb
D. Using heated fans to dry the cast
QUESTION 532The 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. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
QUESTION 533A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
A. Concentrated sweets are taken during increased activity.
B. Food restriction is imposed to reduce weight.
C. Caloric distribution should be calculated to fit activity patterns.
D. Fat requirements are increased owing to the possibility of ketoacidosis.
QUESTION 534A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
A. Encourage the child to cough up blood if present.
B. Give warm clear liquids when fully alert.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
QUESTION 535A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse’s knowledge of the anatomy of
the respiratory system in pediatric clients?
A. The diameter of the trachea is much smaller in children than in adults.
B. The tongue is proportionally smaller in children than in adults.
C. The pediatric airway is more rigid than that of the adults.
D. The length of the pediatric airway is longer in children than in adults.
QUESTION 536A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and
periorbital edema. Which dietary plan is most appropriate for this client?
A. Low-protein diet
B. Low-sodium diet
C. Increased fluid intake
D. High-cholesterol diet
QUESTION 537A 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. “I have taught her to wipe from front to back after urinating.”
B. “I make sure she drinks plenty of fluids every day.”
C. “She enjoys wearing nylon panties, but I make her change them everyday.”
D. “She tries to empty her bladder completely after she urinates, like I told her.”
QUESTION 538A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother’s arms when the nurse approaches. Which approach
is most appropriate at this time?
A. Give the injection in the vastus lateralis site before the child awakens.
B. Awaken the child first and give the injection in the ventrogluteal site.
C. Awaken the child first and give the injection in the dorsogluteal site.
D. Ask the mother to place the child on the examination table and leave the room, and then give the injection in an appropriate site.
QUESTION 539The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber
of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
A. Infuse volume at 44 mL/hr.
B. Infuse volume at 22 mL/hr.
C. Infuse volume at 10 mL/hr.
D. Infuse volume at 30 mL/hr.
QUESTION 540An 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?
A. 240 mL/day
B. 680 mL/day
C. 330 mL/day
D. 960 mL/day
QUESTION 541A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics
of this age group, which nursing measure is most appropriate?
A. Emphasize those aspects of the procedure that require cooperation.
B. Tell the child not to cry or yell.
C. Tell the child that he will get a “stick” in his back.
D. Use medical terminology when explaining the procedure to the client.
QUESTION 542A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be
most successful?
A. Examine the 4 year old first.
B. Provide time for play and becoming acquainted.
C. Have the mother leave the room with one child, and examine the other child privately.
D. Examine painful areas first to get them “over with.”
QUESTION 543An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of
pyloric stenosis?
A. Pain, especially when eating
B. Poor appetite and sucking reflex
C. Increased frequency and quantity of stools
D. Palpable olive-shaped mass in the epigastrium just right of the umbilical cord
QUESTION 544As 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. Auditory training
B. Speech
C. Lip reading
D. Signing
QUESTION 545A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as
part of discharge planning?
A. Give oral iron medication every day.
B. Have the child’s blood pressure monitored every week.
C. Know the signs and symptoms of iron overload.
D. Keep exercise at a minimum to reduce stress.
QUESTION 546An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
A. Partial thromboplastin time
B. Platelet count
C. Complete blood count
D. Bleeding time
QUESTION 547A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the
following explanations by the nurse indicates understanding of this dysfunction?
A. The blood shifts from the right to the left atrium.
B. Surgical closure by suture or patch is recommended before school age.
C. Most atrial septal defects close spontaneously.
D. The child can be treated medically with antibiotics to prevent bacterial endocarditis.
QUESTION 548An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the
nurse include in the discharge instructions?
A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.
B. Disulfiram is most effective when prescribed as late as possible in a recovery program.
C. Disulfiram works on the desensitization principle.
D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.
QUESTION 549An 82-year-old former restaurant owner walks to the nursing station and states, “I have to go. The restaurant opens at 11 am.” Which response by the nurse is the
most appropriate?
A. “Go back to your room. You do not own a restaurant.”
B. “You are in the hospital now. Calm down.”
C. “You once owned a restaurant. Tell me about it.”
D. “It is snowing outside. The restaurant is closed.”
QUESTION 550A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the unit and was found
smoking in the bathroom and spending a large amount of time in the male ward. Which statement by the nurse would best explain to the teenager why she must
follow the rules of the unit?
A. “It is not easy, but the rules must be followed so that everyone can get a fair chance.”
B. “If you do not follow the rules, you will be transferred to the closed, locked unit.”
C. “You are not being fair to the other clients by getting them involved in your deviant behavior.”
D. “Break the rules, all you want, but don’t get caught again!”
QUESTION 551A 45-year-old male client experiences a sense of depression because he has not yet achieved his life’s goals. His career has not been satisfying. He is still looking
for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering
buying a red Corvette convertible. While obtaining these data concerning the client’s feelings about his life, the nurse is able to determine he is experiencing what
psychological crisis according to Erikson’s stages?
A. Identity versus role confusion
B. Integrity versus despair
C. Intimacy versus isolation
D. Generativity versus self-absorption
QUESTION 552A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath,
which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
A. “Why do you feel this way?”
B. “Tell me about your dislike for your parents.”
C. “Don’t worry, everything will be all right on your visit with your parents.”
D. “Perhaps you and I can discover what produces your anxiety.”
QUESTION 553A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable
to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When
educating her about fluoxetine, what might the nurse caution her about?
A. A daily dose of fluoxetine may be taken in the morning or evening.
B. Fluoxetine is not sedating; therefore, restrictions on driving and other hazardous activities are not necessary.
C. Rashes or pruritus usually occur early in the therapy and are treatable without discontinuing the medication.
D. It is safe to take over-the-counter or other prescription medications with fluoxetine.
QUESTION 554A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When
asked about his behavior in the process of the nursing assessment, the client states, “I was mean to my wife because she insists on cooking meals and wearing
clothes that I do not like.” This defense mechanism is an example
of:
A. Repression
B. Regression
C. Reaction formation
D. Rationalization
QUESTION 555A 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. “I understand you’re depressed, but killing yourself is not a reasonable option.”
B. “We need to discuss this further, but right now let’s complete these forms.”
C. “Don’t do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.”
D. “This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.”
QUESTION 556During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting
to the nurse during the interview. The nurse recognizes the behavior and documents it as:
A. Dyskinesia
B. Akathisia
C. Echopraxia
D. Echolalia
QUESTION 557A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she
uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
A. “I did not get the raise because my boss does not like me.”
B. “I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister’s wedding.”
C. “My son died 3 years ago. I still cannot bring myself to clean out his room.”
D. “My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company’s board meeting today.”
QUESTION 558When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
A. Be direct, honest, and attentive.
B. Approach them in the emergency room as soon as you suspect abuse to “clear the air” right away.
C. Ask the parents what they could have done differently to prevent this from happening to the child.
D. After the interview, call child protective services.
QUESTION 559In an interview for suspected child abuse, the child’s mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The
child’s father states, “Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our
child.” Based on this remark, the nurse would make the following nursing diagnosis:
A. Fear related to retaliation by the father
B. Actual injury related to poor impulse control by the father
C. Ineffective coping
D. Altered family process related to physical abuse
QUESTION 560A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after
the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself
financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash
above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?
A. Assess the level of anxiety, coping responses, and support systems.
B. Assess the history of physical abuse.
C. Assess suicide potential.
D. Assess drug and alcohol use.
QUESTION 561As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, “I know I must come to the
hospital, but what do I do next?” You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an
understanding of the examination process once the victim enters the emergency room?
A. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
B. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
C. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
D. Do not leave the victim alone to collect her thoughts.
QUESTION 562A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her
room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5
lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to
the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is
she using?
A. Dissociation
B. Intellectualization
C. Rationalization
D. Displacement
QUESTION 563A 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. Ask him to sit down. Speak slowly and use short, simple sentences.
B. Help him to recognize his anxiety.
C. Walk with him as he paces.
D. Increase the level of his supervision.
QUESTION 564A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable
to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with
friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation
techniques. What result would indicate client education has been successful?
A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
B. He enters a concert, but as the lights dim, he does not experience anxiety.
C. He states that he no longer fears dark places.
D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
QUESTION 565A female client has just died. Her family is requesting that all nursing staff leave the room. The family’s religious leader has arrived and is ready to conduct a
ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing
action, which might include:
A. Inform the family that it is the hospital’s policy not to conduct religious ceremonies in client rooms.
B. Refuse to leave the room because the client’s body is entrusted in the nurse’s care until it can be brought to the morgue.
C. Tell the family that they may conduct their ceremony in the client’s room; however, the nurse must attend.
D. Respect the client’s family’s wishes.
QUESTION 566A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client
education regarding lithium toxicity?
A. Maintain a normal diet; however, limit salt intake to no more than 3 g/day.
B. Take lithium between meals to increase absorption.
C. Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.
D. For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal anti-inflammatory drugs are preferred.
QUESTION 567For the past several months, an elderly female client with Alzheimer’s disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The
family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue
and fingers. This may most likely indicate:
A. Tardive dyskinesia, which may be a side effect of antipsychotic medication
B. Early symptoms of Parkinson’s disease
C. A more advanced stage of Alzheimer’s disease than previously experienced by the client
D. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
QUESTION 568A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to
sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive
behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client’s inpatient stay, which expected outcome is most appropriate?
A. He will attend four consecutive group educational sessions on substance abuse.
B. He will name activities that he would most likely be involved in posttreatment.
C. He will meet with his family in counseling sessions and discuss his feelings.
D. He will be able to deal with his feelings through participation in group therapy sessions.
QUESTION 569A 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. “I should contact my physician if I have headaches after I take this medicine.”
B. “I should keep the tablets in the refrigerator.”
C. “I should call the doctor if three doses of the medicine do not relieve my pain.”
D. “I should take these with water but not with milk.”
.QUESTION 570A client has renal failure. Today’s lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
A. Evaluation of his level of consciousness
B. Evaluation of an electrocardiogram
C. Measurement of his urine output for the past 8 hours
D. Serum potassium lab values for the last several days
QUESTION 571A client’s wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson’s disease, and she is telling his nurse that he has been
doing “strange things.” The nurse reassures the wife that the following behavior is normal with Parkinson’s disease:
A. “Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.”
B. “Your husband may move his hands in motions that look like he is rolling a pill between his fingers.”
C. “Twitching of the muscles is to be expected and can occur at any time during the day.”
D. “Parkinson’s disease causes severe pain in the joints. You should give your husband Tylenol at those times.”
QUESTION 572A male client tells his nurse that he has had an ulcer in the past and is afraid it is “flaring up again.” The nurse begins to ask him specific questions about his
symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:
A. Pain in the middle of the night
B. A bowel movement every 35 days
C. Melena
D. Episodes of nausea and vomiting
QUESTION 573A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps
the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?
A. Offer her oral hygiene before and after meals.
B. Encourage her to consume milk products.
C. Encourage her to engage in an activity before a meal to stimulate her appetite.
D. Restrict her fluid intake to three glasses of water a day.
QUESTION 574A 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. “Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.”
B. “It’s OK for you to donate because the blood bank has a test that is 100% effective.”
C. “You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in
the blood.”
D. “It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.”
QUESTION 575A 50-year-old male client is to receive chemotherapy. The physician’s orders include antiemetics. When planning his care, the nurse should take into consideration
that antiemetics are best administered in the following way:
A. Give antiemetics when nausea is experienced and continue on a regular schedule for 1224 hours.
B. Give antiemetics prior to the client receiving chemotherapy and continue on a regular basis for at least2448 hours after chemotherapy.
C. Give antiemetics one at a time because combinations of antiemetics cause overwhelming side effects.
D. Give antiemetics intermittently during the entire course of chemotherapy.
QUESTION 576A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
A. Respiratory rate of 16 breaths/min
B. Pulse rate of 80 bpm
C. Complaints of muscle aches
D. A sore throat
QUESTION 577Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be
unrealistic?
A. She should be able to control evacuation of her bowels.
B. She should be able to return to a regular diet.
C. She should be able to resume sexual activity.
D. She should be able to manage her own care.
QUESTION 578A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:
A. Cries easily and says she is having abdominal pain
B. Develops a temperature of 102_F
C. Has no bowel sounds
D. Has a urine output of 200 mL for 4 hours
QUESTION 579A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?
A. Teach her to completely clean the skin to remove all ointments and markings after each treatment.
B. Teach her to cover broken skin in the treated area with a medicated ointment.
C. Encourage her to wear a tight-fitting vest to support her scapula.
D. Encourage her to avoid direct sunlight on the area being treated.
QUESTION 580A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the
effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?
A. His weight increases from 165 to 175 lb.
B. His urine output is equal to his total fluid intake.
C. His urine output has been>35 mL/hr for the past 12 hours.
D. His blood pressure is 94/62.
QUESTION 581A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
A. He should monitor his sputum, stools, and urine for signs of bleeding.
B. His daily diet should include a large amount of fluid.
C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.
D. He should not worry about having children because this disease is passed on only by female carriers.
QUESTION 582A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the
two. Which information should the nurse give her to help her decide?
A. Hemodialysis involves less time to filter the blood; but the client must consider travel time, distance, and inconvenience.
B. Hemodialysis involves more time to filter the blood than does peritoneal dialysis.
C. Peritoneal dialysis has almost no complications and is less time consuming than hemodialysis.
Therefore it is preferred.
D. Peritoneal dialysis requires that a home health nurse prepare and administer the treatments.
QUESTION 583A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
A. Assess the site for leakage of blood or fluids
B. Auscultate the site for a bruit
C. Assess the site for bruising or hematoma
D. Inspect the site for color, warmth, and sensation
QUESTION 584A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
A. Warmed solution helps keep the body temperature maintained within a normal range during instillation
B. Warmed solution helps dilate the peritoneal blood vessels
C. Warmed solution decreases the risk of peritoneal infection
D. Warmed solution promotes a relaxed abdominal muscle
QUESTION 585A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
A. Crackles or rales on the affected side
B. Bradypnea and bradycardia
C. Shortness of breath and sharp pain on the affected side
D. Increased breath sounds on the affected side
QUESTION 586A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
A. Instruct the client to cough deeply to re-expand her lung
B. Put on sterile gloves and replace the tube
C. Apply a petrolatum dressing over the site
D. Auscultate the lung to determine if she needs the tube replaced
QUESTION 587A 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?
A. Pain in his legs when he walks
B. Thirst, weight loss, and polyuria
C. Drowsiness and lethargy after his activities
D. Weight gain, edema in his lower extremities, and shortness of breath
QUESTION 588A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her
teaching when the client tells her:
A. “He should remove the electrodes for bathing.”
B. “Damage to his heart muscle will be recorded by the monitor.”
C. “He is to keep a record of everything he does during the day.”
D. “He is to refrain from activities that cause chest pain.”
QUESTION 589To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
A. Dangle the client’s legs over the edge of the bed every shift.
B. Massage the client’s calves briskly every shift.
C. Keep the client’s legs extended and discourage any movement.
D. Have the client tighten and relax leg muscles several times daily.
QUESTION 590A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
A. Encourage exercises in the unaffected extremities.
B. Encourage her to cross and uncross her legs.
C. Check neurological and circulatory status of the affected leg hourly.
D. Place a trochanter roll along the upper thigh of the affected leg.
QUESTION 591A male client has a history of diverticulosis. He has questions about the foods that he should eat.
His nurse gives him the following information:
A. He should be on a high-fiber diet.
B. He should eat a low-residue diet.
C. He should drink minimal amounts of fluids.
D. He does not need to make any modifications.
QUESTION 592A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after
birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:
A. Place her under the radiant warmer
B. Dry her with blankets
C. Place her to her mother’s breast
D. Place her on a heated pad
QUESTION 593A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately
following delivery, the nurse would expect the fundus to be located:
A. At the umbilicus
B. At the symphysis pubis
C. Midway between the umbilicus and the xiphoid process
D. Midway between the umbilicus and the symphysis pubis
QUESTION 594A 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:
A. Stage 2, latent phase
B. Stage 1, active phase
C. Stage 3, transition phase
D. Stage 1, latent phase
QUESTION 595A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, “Nurse, the baby is
coming.” As the nurse responds to her call, which one of the following observations should the nurse make first?
A. Inspect the perineum.
B. Time the contractions.
C. Prepare a sterile area for delivery.
D. Auscultate for fetal heart rate (FHR).
QUESTION 596A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg.
The nurse’s first action would be to:
A. Call the physician immediately and give dopamine IM
B. Turn her on her left side and recheck her blood pressure in 5 minutes
C. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids
D. Increase the rate of IV fluids and start O2 by mask
QUESTION 597A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice
before. She had a “miscarriage” with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks’ gestation. One of the twins
was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:
A. 2-0-2-1-0
B. 2-2-2-1-2
C. 3-0-1-1-0
D. 2-1-1-0-0
QUESTION 598A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was
February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
A. November 23rd
B. December 26th
C. September 14th
D. December 9th
QUESTION 599On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some
milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
B. Allow the infant to breast-feed at the next feeding time to empty the breasts
C. Apply ice packs to the breasts and wear a supportive, well-fitting bra
D. Take a warm shower and express milk from both breasts until empty
QUESTION 600A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the
legal standard of practice?
A. State nursing practice act
B. AWHONN Standards for the Nursing Care of Women and Newborns
C. American Nurses’ Association Standards of Maternal- Child Health Nursing
D. International Council of Nurses’ Code
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