Cheyne-Stokes respiratory pattern can be associated with which of the following conditions?

Cheyne-Stokes respiratory pattern can be associated with which of the following conditions?

 

A. Diabetic ketoacidosis

 

B. Fever

 

C. Increased intracranial pressure

 

D. Spinal meningitis

 

QUESTION 302When 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?

 

A. Potassium

 

B. Magnesium

 

C. Sodium

 

D. HCO3

 

QUESTION 303A 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 304Which of the following blood gas parameters primarily reflects respiratory function?

 

A. PCO2

 

B. CO2 content of the blood

 

C. HCO3

 

D. Base excess

 

QUESTION 305Endotracheal tube cuff pressure should never exceed:

 

A. 10 mm Hg

 

B. 20 mm Hg

 

C. 45 mm Hg

 

D. 60 mm Hg

 

QUESTION 306The 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 307A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority

 

in the first 8 hours’ postburn?

 

A. Fluid volume deficit secondary to alteration in skin integrity

 

B. Alteration in comfort secondary to alteration in skin integrity

 

C. Alteration in sensation secondary to third-degree burn

 

D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity

 

QUESTION 308A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal

 

bottle of a three-bottle chest drainage system serves which of the following purposes?

 

A. Collection bottle for drainage

 

B. Pressure regulator

 

C. Preventing accumulation of blood around the heart

 

D. Preventing air from entering the chest upon inspiration

 

QUESTION 309Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

 

A. Creatinine

 

B. Sodium

 

C. Calcium

 

D. Potassium

 

QUESTION 310While changing the dressing on a client’s central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be

 

appropriate to implement based on this finding?

 

A. Discontinue the central line.

 

B. Begin a peripheral IV.

 

C. Document in the nurse’s notes and notify the physician after redressing the site.

 

D. Clean the site well and redress.

 

QUESTION 311The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube

 

feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse

 

notices the sputum to be a blue color. This is indicative of which of the following?

 

A. The client aspirated tube feeding.

 

B. The nurse has placed the suction catheter in the esophagus.

 

C. This is a normal finding.

 

D. The feeding is infusing into the trachea.

 

QUESTION 312The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this

 

client?

 

A. Morphine sulfate

 

B. Kerolac tromethamine (Toradol)

 

C. Promethazine (Phenergan)

 

D. Meperidine (Demerol)

 

QUESTION 313The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first

 

nursing action after assessing this finding?

 

A. Palpate these pulses again in 15 minutes.

 

B. Use a Doppler to determine presence and strength of these pulses.

 

C. Document the finding that the pulses are not palpable.

 

D. Call the physician and notify the physician of this finding.

 

QUESTION 314The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?

 

A. Increase in gastric secretions

 

B. Increase in peristalsis

 

C. Disorientation

 

D. Drowsiness

 

QUESTION 315A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his

 

next of kin. The sequence in which the next of kin would be asked for the consent would be:

 

A. Parent, spouse, adult child, sibling

 

B. Spouse, adult child, parent, sibling

 

C. Spouse, parent, sibling, adult child

 

D. Parent, spouse, sibling, adult child

 

QUESTION 316A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would

 

document this as what type of drainage?

 

A. Serosanguinous

 

B. Purulent

 

C. Sanguinous

 

D. Catarrhal

 

QUESTION 317A 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:

 

A. Excoriation

 

B. Dehiscence

 

C. Decortication

 

D. Evisceration

 

.QUESTION 318The nurse documents a client’s surgical incision as having red granulated tissue. This indicates that the wound is:

 

A. Infected

 

B. Not healing

 

C. Necrotic

 

D. Healing

 

QUESTION 319A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and

 

dusky. The nurse should:

 

A. Continue to monitor the foot

 

B. Notify the physician immediately

 

C. Reposition and reassess the foot

 

D. Assure the client that his foot is fine

 

QUESTION 320A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal

 

mammary artery for his bypass graft because his friend’s physician uses this artery. The nurse tells the client that the internal mammary artery:

 

A. Takes more time to remove

 

B. Has a greater risk of becoming reoccluded

 

C. Is smaller in diameter

 

D. Has too many valves

 

QUESTION 321A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse

 

needs to monitor will be:

 

A. Chloride

 

B. HCO3

 

C. Potassium

 

D. Sodium

 

QUESTION 322A 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 11/2 inches larger than the stoma

 

C. Changing the pouch only when leakage occurs

 

D. Using a skin sealant under pouch adhesives

 

QUESTION 323A 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 324A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:

 

A. Remind the client that he no longer has that part of his leg and assure him he will be OK

 

B. Call the physician to request a psychological consultation for the client

 

C. Turn on the television to distract the client’s attention from his amputated leg

 

D. Give the client his order of Demerol 50 mg IM prn

 

QUESTION 325A 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

 

B. Hypercalcemia

 

C. Fistula formation

 

D. Myxedema

 

QUESTION 326A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the

 

blood in his urine:

 

A. Should not be there on the second day

 

B. Will stop when the Foley catheter is removed

 

C. Is normal and he need not be concerned about it

 

D. Can be removed by irrigating the bladder

 

QUESTION 327A 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 328A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing

 

diagnosis for her will be high risk for:

 

A. Knowledge deficit

 

B. Urinary retention

 

C. Impaired physical mobility

 

D. Ineffective breathing pattern

 

QUESTION 329A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy

 

would include:

 

A. Monitoring the chest tubes

 

B. Positioning the client on the right side

 

C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back

 

D. Monitoring the right lung for an increase in rales

 

QUESTION 330A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

 

A. Reinforce the dressing.

 

B. Continue to monitor the dressing.

 

C. Notify the physician.

 

D. Note the time and amount of blood.

 

QUESTION 331A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is

 

experiencing which type of rejection?

 

A. Acute

 

B. Chronic

 

C. Hyperacute

 

D. Hyperchronic

 

QUESTION 332A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching

 

has been effective when the client states:

 

A. “I know I will need special swallowing training after my surgery.”

 

B. “The quality of my voice will be excellent after surgery.”

 

C. “I will have very little difficulty swallowing after surgery.”

 

D. “I may also have to have a radical neck dissection done.”

 

QUESTION 333A 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 334A 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 335On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty.He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. Theclient is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?

 

A. “You will not be allowed to remain in your room if you continue to bother things.”

 

B. “I can see how uncomfortable you are, but I would like you to walk with me so I can show you around the unit.”

 

C. “Tell me why your room needs to be so clean.”

 

D. “I’ve inspected this room and it is perfectly clean.”

 

QUESTION 336

 

The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?

 

A. Prolonged use of this medication will result in extrapyramidal side effects.

 

B. When the medication is effective, he will experience no anxiety.

 

C. The medication should relieve his symptoms of depression.

 

D. Blood must be drawn weekly to test for toxicity.

 

QUESTION 337The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:

 

A. Reduce his anxiety

 

B. Avoid going to psychotherapy

 

C. Manipulate the health team members

 

D. Increase his self-image by showing higher standards than the fellow clients

 

QUESTION 338A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization.She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client’s behavior can be

 

described as:

 

A. Housework phobia

 

B. Malingering

 

C. Conversion reaction

 

D. Agoraphobia

 

QUESTION 339A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in

 

desperation, has admitted him to the hospital’s psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the

 

best approach to this problem is to:

 

A. Allow him to eat late

 

B. Suggest that he do the rituals after breakfast

 

C. Get him up early so that he can complete the ritual before breakfast

 

D. Ask him to get all the other clients up so that he will forget about his ritual

 

QUESTION 340A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner

 

in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the

 

therapist, he informed him or her that he was a busy man and did not have much time for this “psych stuff.” When guiding the client to ventilate his feelings, the

 

therapist can expect him to express feelings of:

 

A. Guilt

 

B. Shame

 

C. Despair

 

D. Anger

 

QUESTION 341Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:

 

A. His priority needs are limited to medical management

 

B. There is no real psychological basis for his illness

 

C. The disorder is a threat to his physical well-being

 

D. He is unable to participate in planning his care

 

QUESTION 342A 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 agoraphobia. 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 343A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her

 

time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being “bugged.” Her diagnosis is schizophrenia. One nurse

 

per shift is assigned to work with the client. The primary reason for this plan would be to:

 

A. Protect her from suicide

 

B. Enable her to develop trust

 

C. Supervise her medication regimen

 

D. Involve her in groups for social interaction

 

QUESTION 344The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being

 

allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:

 

A. Hypotension

 

B. Photosensitivity

 

C. Excessive appetite

 

D. Dryness of the mouth

 

QUESTION 345Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A

 

nursing intervention basic to improving withdrawn behavior is:

 

A. Assigning her to occupational therapy

 

B. Having her sit with the nurses while they chart

 

C. Helping her to make friends

 

D. Facilitating communication

 

QUESTION 346A 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

 

B. Delusions

 

C. Hallucinations

 

D. Echolalia

 

QUESTION 347A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may

 

occur with lithium therapy when the blood level is above:

 

A. 1.0 mEq/L

 

B. 2.2 mEq/L

 

C. 0.03 mEq/L

 

D. 1.5 mEq/L

 

QUESTION 348A client’s behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

 

A. Seclude him in his room.

 

B. Set limits on his behavior.

 

C. Have his medication increased.

 

D. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.

 

QUESTION 349A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her

 

hyperactive state. The most therapeutic nursing action is to:

 

A. Insist that she remain at the table and eat a balanced diet.

 

B. Order a high-calorie diet with supplements.

 

C. Provide nutritious finger foods several times a day.

 

D. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.

 

QUESTION 350A 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 351A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is

 

most likely to occur is:

 

A. In the acutely depressed state

 

B. When the depression starts to lift

 

C. In the denial phase

 

D. During a manic episode

 

QUESTION 352Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug isto:

 

A. Relax muscles

 

B. Relieve anxiety

 

C. Reduce secretions

 

D. Act as an anesthetic

 

QUESTION 353

 

The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcareprovider is:

 

A. Constipation

 

B. Urinary frequency

 

C. Breast tenderness

 

D. Abdominal pain

 

QUESTION 354At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks’ gestation and has a history of drug abuse, smoking, and

 

occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant’s intrauterine growth retardation is:

 

A. The client’s young age

 

B. The client’s previous abortion

 

C. The client’s history of drug, ethyl alcohol, and tobacco use

 

D. The client’s late prenatal care

 

QUESTION 355When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 48) 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 356What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?

 

http://www.gratisexam.com/

 

A. Human chorionic gonadotropin

 

B. Estrogen

 

C. -fetoprotein

 

D. Sphingomyelin

 

QUESTION 357A 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 358A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client’s glucose tolerance test shows elevated blood sugar levels.

 

Because she only shows signs of diabetes when she is pregnant, she is classified as having:

 

A. Insulin-dependent diabetes

 

B. Type II diabetes mellitus

 

C. Type I diabetes mellitus

 

D. Gestational diabetes mellitus

 

QUESTION 359Prior 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 360A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks’ gestation. Based on the nurse’s knowledge of the maternal physiological changes in

 

pregnancy, which of these findings would be of concern?

 

A. Complaints of dyspnea

 

B. Edema of face and hands

 

C. Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks

 

D. Hematocrit 39%

 

QUESTION 361Based 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 362Chorioamnionitis is a maternal infection that is usually associated with:

 

A. Prolonged rupture of membranes

 

B. Postterm deliveries

 

C. Maternal pyelonephritis

 

D. Maternal dehydration

 

QUESTION 363A client has been diagnosed with thrombophlebitis. She asks, “What is the most likely cause of thrombophlebitis during my pregnancy?” The nurse explains:

 

A. Increased levels of the coagulation factors and a decrease in fibrinolysis

 

B. An inadequate production of platelets

 

C. An inadequate intake of folic acid during pregnancy

 

D. An increase in fibrinolysis and a decrease in coagulation factors

 

QUESTION 364Following 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?

 

A. Dysuria

 

B. Epistaxis, hematuria, dysuria

 

C. Vertigo, hematuria, ecchymosis

 

D. Hematuria, ecchymosis, and epistaxis

 

QUESTION 365A 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 366A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks’ gestation and is

 

carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the

 

client is experiencing mild uterine contractions every 78 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:

 

A. Her cervix shows she will likely deliver soon

 

B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks’ gestation

 

C. She may be in preterm labor because this is more common with multiple pregnancies

 

D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy

 

QUESTION 367The most frequent cause of early postpartum hemorrhage is:

 

A. Hematoma

 

B. Coagulation disorders

 

C. Uterine atony

 

D. Retained placental fragments

 

QUESTION 368A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse

 

attempts to take her vital signs, she responds in anger, stating, “You leave me alone. You don’t care anything about me. It’s people like you who let my baby die.”

 

The nurse’s best course of action is to:

 

A. Quietly leave her room, allowing her more private time to deal with her loss.

 

B. Tell her that what happened was for the best and that she is still young and can have other children.

 

C. Tell her how sorry you are, and let her know that her child is now a little angel in heaven.

 

D. Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.

 

QUESTION 369When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and

 

not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

 

A. A large gush of clear fluid from the vagina

 

B. Systolic hypertension

 

C. Abdominal rigidity

 

D. Increased fetal movements

 

QUESTION 370

 

A mother called the physician’s office to ask if it would help relieve her small daughter’s abdominal pain if she gave an enema and placed a heating pad on the

 

abdomen. Her daughter has a fever and has vomited twice.

 

The nurse’s response is based on the knowledge that:

 

A. The symptoms could easily have been caused by constipation, which an enema would relieve

 

B. Heat would help to relax the abdominal muscles and relieve her pain

 

C. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation

 

D. Complaints of stomach ache are common in young children and are generally best ignored

 

QUESTION 371An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will

 

be most helpful for the nurse to:

 

A. Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room

 

B. Take time to orient the child and her family to the hospital and the forthcoming events

 

C. Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has

 

D. Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as “good as new”

 

QUESTION 372Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end

 

of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:

 

A. The nurse may lift only the weights that are applying traction in order to reposition him in bed

 

B. The client will need special skin care at the pin site according to hospital policy or the physician’s preference

 

C. The traction pull should result in an immediate increase in comfort and reduce the need for pain medication

 

D. The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction

 

QUESTION 373A 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 374Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:

 

A. Moving or turning the client’s left leg carefully to minimize pain and discomfort

 

B. Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing on the left leg

 

C. Providing the client with a high-protein, high-fiber diet to promote healing

 

D. Instituting physical therapy to ensure restoration of optimal functioning of the leg

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTION 375Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother

 

appears anxious and asks what she could have done to prevent the exacerbation. The nurse’s response is based on the knowledge that chronic osteomyelitis:

 

A. Is caused by poor physical conditions or poor nutrition

 

B. Often results from unhygienic conditions or an unclean environment

 

C. Is directly related to sluggish circulation in the affected limb

 

D. May develop from sinuses in the involved bone that retain infectious material

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