This is a 40-item sample questions with rationales in preparation for the 2014 Philippine Nurse Licensure Exam1. A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A) digoxin (Lanoxin) B) diltiazam (Cardizem) C) nitroglycerine ointment D) metoprolol (Toprol XL) The correct answer is A: digoxin (Lanoxin) Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability 2. Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first? A) An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago." B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy C) A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past week D) A teenager with a history of falling off a bicycle and did not hit the handle bars The correct answer is A: An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago." This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured as based on the history of the pain suddenly stopping over three hours ago. Being elderly there, is less reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also. However, given that they fall in younger age groups, they would more likely be able to tolerate an inbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen. 3. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence C) Justice D) Autonomy The correct answer is D: Autonomy Individuals must be free to make independent decisions about participation in research without coercion from others. 4. Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? A) “It is to observe reactive service and product problem solving." B) Improvement of the processes in a proactive, preventive mode is paramount. C) A chart audits to finds common errors in practice and outcomes associated with goals. D) A flow chart to organize daily tasks is critical to the initial stages. The correct answer is B: Improvement of the processes in a proactive, preventive mode is paramount. Total quality management and continuous quality improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problem-solving. 5. A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention? A) Decreased blood pressure and respirations. B) Flushing and headache. C) Restlessness and palpitations. D) Increased heart rate and blood pressure. The correct answer is C: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations 6. When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included? A) Tachycardia blurred vision, hypotension, anorexia B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods C) Diarrhea, dry mouth, weight loss, reduced libido D) Photosensitivity, seizures, edema, hyperglycemia The correct answer is C: Diarrhea, dry mouth, weight loss, reduced libido Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido 7. The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for agastostomy tube placement, the priority is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) Place the end of the tube in water to check for air bubbles C) Retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium The correct answer is A: Auscultate the abdomen while instilling 10 cc of air into the tube If a swoosh of air is heard over the abdominal cavity while instilling air into the gastric tube, this indicates that it is accurately placed in the stomach. The feeding can begin after assessing the client for bowel sounds 8.Which of these questions is priority when assessing a client with hypertension? A) "What over-the-counter medications do you take?" B) "Describe your usual exercise and activity patterns." C) "Tell me about your usual diet." D) "Describe your family's cardiovascular history." The correct answer is A: "What over-the-counter medications do you take?" Over-the-counter medications, especially those that contain cold preparations can increase the blood pressure to the point of hypertension. 9. The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is anappropriate finger food? A) Hot dog pieces B) Sliced bananas C) Whole grapes D) Popcorn The correct answer is B: Sliced bananas Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and can occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed 10 client is ordered warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse’s discharge instruction? A) Maintain a consistent intake of green leafy foods B) Report any nose or gum bleeds C) Take Tylenol for minor pains D) Use a soft toothbrush The correct answer is B: Report any nose or gum bleeds The client should notify the health care provider if blood is noted in their stools or urine, or any other signs of bleeding occ 11. The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse? A) Decreased breath sounds in right lower lobe The client's total protein level is reported as 4. Check for tube placement prior to each feeding or every 4 to 8 hours if continuous feeding 12.0-8. While the parents focus on the needs of this child. (A normal total serum protein level is 6.) TPN will maintain a positive nitrogen balance in the client who is unable to digest and absorb nutrients adequately.5. To minimize the side effects.B) Aspiration of a residual of 100cc of formula C) Decrease in bowel sounds D) Urine output of 250 cc in past 8 hours The correct answer is A: Decreased breath sounds in right lower lobe The most common problem associated with enteral feedings is atelectasis. The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma.0. the nurse should emphasize which of the following actions? A) Reporting joint stiffness in the morning B) Taking the medication 1 hour before or 2 hours after meals C) Using alcohol in moderation unless driving . Which of the following would the nurse anticipate? A) Additional potassium will be given IV B) Blood for coagulation studies will be drawn C) Total parenteral nutrition (TPN) will be started D) Serum lipase levels will be evaluated The correct answer is C: Total parenteral nutrition (TPN) will be started The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. they should be aware that the risk is high for future offspring Question Number 13 of 40 The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. A priority in communicating with the parents is A) Discuss the need for genetic counseling B) Inform them that combined therapy is seldom effective C) Prepare for the child's permanent disfigurement D) Suggest that total blindness may follow surgery The correct answer is A: Discussing the need for genetic counseling The hereditary aspects of this disease are well documented. Question Number 14 of 40 The nurse is teaching about nonsteroidal anti-inflammatory drugs to a group of arthritic clients. Maintain client at 30 degrees during feedings and monitor for signs of aspiration. Puerto Ricans. which are symbolic designations and do not necessarily indicate temperature or spiciness. The client states “I refuse both radiation and chemotherapy because they are 'hot.D) Continuing to take aspirin for short term relief The correct answer is B: Taking the medication 1 hour before or 2 hours after meals Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect. Sensitivity to these will affect interactions with clients and families across cultures. Elevation indicates elevated glucose levels over time. and other Hispanic-Latinos. herbs.'” The next action for the nurse to take is to A) Document the situation in the notes B) Report the situation to the health care provider C) Talk with the client's family about the situation D) Ask the client to talk about the concerns about the "hot" treatments The correct answer is D: Ask the client to talk about the concerns about the "hot" treatments The "hot-cold" system is found among Mexican-Americans. Question Number 17 of 40 During a routine check-up. Question Number 15 of 40 Which approach is a priority for the nurse who works with clients from many different cultures? A) Speak at least 2 other languages of clients in the neighborhood B) Learn about the cultures of clients who are most often encountered C) Have a list of persons for referral when interaction with these clients occur D) Recognize personal attitudes about cultural differences and real or expected biases The correct answer is D: Recognize personal attitudes about cultural differences and real or expected biases The nurse must discover personal attitudes. The results indicate a level of 11%. what teaching should the nurse emphasize? A) Rotation of injection sites B) Insulin mixing and preparation C) Daily blood sugar monitoring D) Regular high protein diet The correct answer is C: Daily blood sugar monitoring Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Question Number 16 of 40 A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. beverages. Care and treatment regimens can be negotiated with clients within this framework. an insulin-dependent diabetic has his glycosylated hemoglobin checked. Most foods. . Based on this result. prejudices and biases specific to different cultures. and medicines are categorized as hot or cold. Question Number 18 of 40 The nurse is assigned to care for 4 clients. Therefore. vomiting and abdominal distention. The client should be assessed immediately and findings reported to the health care provider Question Number 19 of 40 To prevent drug resistance common to tubercle bacilli. Which of the following should be assessed immediately after hearing the report? A) The client with asthma who is now ready for discharge B) The client with a peptic ulcer who has been vomiting all night C) The client with chronic renal failure returning from dialysis D) The client with pancreatitis who was admitted yesterday The correct answer is B: The client with a peptic ulcer who has been vomiting all night A perforated peptic ulcer could cause nausea. Question Number 20 of 40 While assessing the vital signs in children. the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? A) 1 year of age B) 2 years of age C) 3 years of age D) 4 years of age The correct answer is B: 2 years of age A child should be at least 2 years of age to use the radial pulse to assess heart rate. the nurse is aware that which of the following agents are usually added to drug therapy? A) Anti-inflammatory agent B) High doses of B complex vitamins C) Aminoglycoside antibiotic D) Two anti-tuberculosis drugs The correct answer is D: Two anti-tuberculosis drugs Resistance of the tubercle bacilli often occurs to a single antimicrobial agent. therapy with multiple drugs over a long period of time helps to ensure eradication of the organism. and may be a life threatening situation. Question Number 21 of 40 Which of these clients would the nurse monitor for the complication of C. difficile diarrhea? A) An adolescent taking medications for acne B) An elderly client living in a retirement center taking prednisone . Also. and cephalosporins.C) A young adult at home taking a prescribed aminoglycoside D) A hospitalized middle aged client receiving clindamycin The correct answer is D: A hospitalized middle aged client receiving clindamycin Hospitalized patients. C. nafcillin. and trimethoprim are seldom associated with C. Of patients receiving antibiotics. The best technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit The correct answer is D: Gentle pressure on eye orbit This is an acceptable stimuli only after progressing from lighter to stimuli to more obnoxious. clavulanic acid. oxacillin). such as clindamycin. difficile. Several antibiotic agents have been associated with C. difficile infection has been caused by the administration of agents containing beta-lactamase inhibitors (ie. Question Number 24 of 40 The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. Detailed explanations are not helpful. ampicillin. ceftriaxone. Question Number 23 of 40 The nurse is performing an assessment of the motor function in a client with a head injury. difficile. Which of the following actions should the nurse do first? A) Explain that the procedure will help him to get well B) Show a cartoon character with a blood pressure cuff C) Explain that the blood pressure checks the heart pump D) Permit handling the equipment before putting the cuff in place The correct answer is D: Permit handling the equipment before putting the cuff in place The best way to gain the toddler''s cooperation is to encourage handling the equipment. vancomycin. sulbactam. The nurse recognizes that. C. difficile causes 15 to 20% of the cases. Fluoroquinolones. especially those receiving antibiotic therapy. aminoglycosides. amoxicillin. Question Number 22 of 40 The nurse is preparing to take a toddler's blood pressure for the first time. as a result of the radiation therapy. tazobactam) and intravenous agents that achieve substantial colonic intraluminal concentrations (ie. the client is most likely to experience A) High fever B) Nausea . are the most frequent sources of C. difficile infection or pseudomembranous colitis. difficile. Broad-spectrum agents. 5-38% experience antibiotic-associated diarrhea. are primary targets for C. Which action by the nurse should take priority? A) Check that the catheter tip is intact B) Apply a pressure dressing to the site C) Monitor respiratory status D) Assess for mental status changes .5-2. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. Which of these mediations would the nurse anticipate the health care provider ordering? A) Oral Coumadin therapy B) Heparin 5000 units subcutaneously b.5 times the control value D) Heparin by subcutaneous injection to maintain the PTT at 1. the nausea is especially troubling Question Number 25 of 40 A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE).i.d. Question Number 26 of 40 A newborn weighed 7 pounds 2 ounces at birth.C) Face and neck edema D) Night sweats The correct answer is B: Nausea Because the client with Hodgkin''s disease is usually healthy when therapy begins.5 times the control value The correct answer is D: Heparin by subcutaneous injection to maintain the PTT at 1. Warfarin (Coumadin) is known to cross the placenta and is therefore reported to be teratogenic. What should the nurse tell the parents about this weight loss? A) The newborn needs additional assessments B) The mother should breast feed more often C) A change to formula is indicated D) The loss is within normal limits The correct answer is D: The loss is within normal limits A newborn is expected to lose 5-10% of the birth weight in the first few days because of changes in elimination and feeding. Question Number 27 of 40 A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter.5 times the control value Several studies have been conducted in pregnant women where oral anticoagulation agents are contraindicated. C) Heparin infusion to maintain the PTT at 1. The catheter accidentally becomes dislodged from the site. " B) "A beta-Blocker will prevent orthostatic hypotension. the nurse notes several physical changes. A nursing student asks the charge nurse why this drug would be used by a client who is not hypertensive. is given a prescription for a betablocking drug. Question Number 29 of 40 A client is brought to the emergency room following a motor vehicle accident.The correct answer is B: Apply a pressure dressing to the site The client is at risk of bleeding or the development of an air embolus if the catheter exit site is not covered immediately Question Number 28 of 40 A client with a panic disorder has a new prescription for Xanax (Alpazolam). This is a medical emergency. In teaching the client about the drug's actions and side effects. What is an appropriate response by the charge nurse? A) "Most people develop hypertension following an MI." The correct answer is C: "This drug will decrease the workload on his heart." D) "Beta-blockers increase the strength of heart contractions. and will reduce the risk of another MI or sudden death . which of the following should the nurse emphasize? A) Short-term relief can be expected B) The medication acts as a stimulant C) Dosage will be increased as tolerated D) Initial side effects often continue The correct answer is A: Short-term relief can be expected Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly. Question Number 30 of 40 A client being discharged from the cardiac step-down unit following a myocardial infarction ( MI). When assessing the client one-half hour after admission. Which changes would require the nurse's immediate attention? A) Increased restlessness B) Tachycardia C) Tracheal deviation D) Tachypnea The correct answer is C: Tracheal deviation The deviated trachea is a sign that a mediastinal shift has occurred. This is useful for the client with coronary artery disease." One action of beta-blockers is to decrease systemic vascular resistance by dilating arterioles." C) "This drug will decrease the workload on his heart. 25. Which recommendation made by the nurse would be most helpful to the client? A) Avoid liquids unless a thickening agent is used B) Sit upright for at least 1 hour after eating C) Maintain a diet of soft foods and cooked vegetables D) Avoid eating 2 hours before going to sleep The correct answer is D: Avoid eating2 hours before going to sleep Eating before sleeping enhances the regurgitation of stomach contents which have increased acidity into the esophagus. the mother indicates that the child has not had the first measles.7-3. the nurse performs a dextro-stick at 1 hour post birth.3 mmol/L. and should be given at this time. rubella (MMR) immunization. Normal values are: Premature infant: 20-60 mg/dl or 1. immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. When the nurse obtains the child's health history. Question Number 34 of 40 .1-3. Post-transplant. Maintaining an upright posture should be for about 2 hours after eating to allow for the stomach emptying. Because of the increased birth weight which can be associated with diabetes mellitus.Question Number 31 of 40 A client has gastroesophageal reflux. repeated blood sugars will be drawn. Question Number 33 of 40 An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl.3 mmol/L. The nurse understands that which of the following is true in regards to giving immunizations to this child? A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now.0 mmol/L. Infant: 40-90 mg/dl or 2. The serum glucose reading is 45 mg/dl. prior to the transplant C) An inactivated form of the vaccine can be given at any time D) The risk of vaccine side effects precludes giving the vaccine The correct answer is B: The MMR vaccine should be given now. mumps. What action by the nurse is appropriate at this time? A) Give oral glucose water B) Notify the pediatrician C) Repeat the test in 2 hours D) Check the pulse oximetry reading The correct answer is C: Repeat the test in two hours This blood sugar is within the normal range for a full-term newborn. prior to the transplant MMR is a live virus vaccine. The options A and C are interventions for clients with swallowing difficulties Question Number 32 of 40 As a part of a 9 pound full-term newborn's assessment. Neonate: 30-60 mg/dl or 1. diaphoresis and nausea. Continuing to use drugs has the potential to impact parenting behaviors. Social service referrals are indicated Question Number 36 of 40 The nurse admits a 2 year-old child who has had a seizure. In order to provide continuity of care. diagnosed with a myocardial infarction." D) "He seems to be going to the bathroom more frequently. is complaining of substernal chest pain. The client." The correct answer is B: "He has had an ear infection for the past 2 days. The first action by the nurse should be A) Order an EKG B) Administer morphine sulphate C) Start an IV D) Measure vital signs The correct answer is B: Administer pain medication as ordered Decreasing the clients pain is the most important priority at this time. Question Number 35 of 40 The clinic nurse is counseling a substance-abusing post partum client on the risks of continued cocaine use. which nursing diagnosis is a priority ? A) Social isolation B) Ineffective coping C) Altered parenting D) Sexual dysfunction The correct answer is C: Altered parenting The cocaine abusing mother puts her newborn and other children at risk for neglect and abuse." Contributing factors to seizures in children include those such as age (more common in first 2 years).A nurse admits a client transferred from the emergency room. fatigue. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week. Morphine will decrease the oxygen demands of the heart and act as a mild diuretic as well. As long as pain is present there is danger in extending the infarcted area. not eating properly and excessive fluid intake or fluid retention Question Number 37 of 40 Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? . infections (late infancy and early childhood)." C) "He has been eating more red meat lately." B) "He has had an ear infection for the past 2 days. Which of the following should be included in the plan of care? A) Encourage child to engage in activities in the playroom B) Promote independence in activities of daily living C) Talk with the child and allow him to express his opinions D) Provide frequent reassurance and cuddling The correct answer is A: Encourage child to engage in activities in the playroom According to Erikson. the school age child is in the stage of industry versus inferiority. which statement is a priority to consider for the ethical guidelines of the nurse? A) The client's self-report is the most important consideration B) Cultural sensitivity is fundamental to pain management C) Clients have the right to have their pain relieved D) Nurses should not prejudge a client's pain using their own values . Question Number 39 of 40 The nurse is planning care for an 8 year-old child. the nurse should encourage them to carry out tasks and activities in their room or in the playroom Question Number 40 of 40 During a situation of pain management. The client should be instructed to immediatley report which of these? A) Double vision and visual halos B) Extremity tingling and numbness C) Confusion and lightheadedness D) Sensitivity of sunlight The correct answer is B: Extremity tingling and numbness Peripheral neuropathy is the most common side effect of INH and should be reported to the health care provider. it can be reversed. To help them achieve industry.A) Benzodiazephines B) Chlorpromazine (Thorazine) C) Succinylcholine (Anectine) D) Thiopental sodium (Pentothal Sodium) The correct answer is C: Succinylcholine (Anectine) Succinylcholine is given intravenously to promote skeletal relaxation Question Number 38 of 40 A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. She elevates the head of the bed to the high Fowler position. The nurse discusses the foods allowed on a 500-mg low sodium diet. The four main concepts common to nursing that appear in each of the current conceptual models are: a. Reporting an APTT above 45 seconds to the physician c. The physician orders a platelet count to be performed on Mrs. Adams begins to have increased difficulty breathing. The nurse documents this breathing as: a. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be… a. Elimination c. The nurse is responsible for: a. Administer oxygen by Venturi mask at 24%. health. environment. The physician orders a maintenance dose of 5. All of the above 6.000 units of subcutaneous heparin (an anticoagulant) daily. Writing the order for this test c. b. nursing d. Assessing the patient for signs and symptoms of frank and occult bleeding d. Person. Mashed potatoes and broiled chicken c. Person. Person. Allow a 1 hour rest period between activities 2. health. nursing. FUNDAMENTALS OF NURSING QUESTIONS WITH RATIONALES 1. Maintain the patient in an orthopneic position as needed c. environment. In Maslow’s hierarchy of physiologic needs. Mitchell now include: a. All of the above 4.The nurse observes that Mr. Giving the patient breakfast d. medicine b. the human need of greatest priority is: a. These include: a. as needed d. psychology. Instructing the patient about this diagnostic test b. Hyperventilation 3. Nutrition . Pain is whatever the client says it is. Smith after breakfast. Mitchell has been given a copy of her diet. Person. Nursing responsibilities for Mrs. nursing 7. nursing. Tachypnea b. health. support systems c. The other statements are correct but not the priority. A tossed salad with oil and vinegar and olives d. Eupnca c. which decreases his respiratory distress. Love b. A ham and Swiss cheese sandwich on whole wheat bread b. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. Maintain the patient on strict bed rest at all times b. Mrs.The correct answer is A: The client''s self-report is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. Chicken bouillon 5. Orthopnea d. The holistic approach provides for a therapeutic relationship. Assault d. The nurse administers penicillin to a patient with a documented history of allergy to the drug. Discuss the problem with her supervisor d. If nurse administers an injection to a patient who refuses that injection. A new head nurse on a unit is distressed about the poor staffing on the 11 p. The nurse could be charged with: a. Assault and battery b. Negligence c. Wait until she knows more about the unit c. the nurse could be held liable for: a. Malpractice d. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. Discourage them from making a decision until their grief has eased b. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? a. Oxygen 8. None of the above 12. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. Battery d. shift. Autonomy and authority for planning are best delegated to a nurse who knows the patient well c. and efficient nursing care. to 7 a. cost-effective nursing care b. Tell them the body will not be available for a wake or funeral 9. What should she do? a. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent. What should the nurse do? a. suffering a skull fracture. Malpractice 14. 11. Complain to her fellow nurses b. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. A registered nurse reaches to answer the telephone on a busy pediatric unit. Inform the staff that they must volunteer to rotate 10. Slander b. b. Continuity of patient care promotes efficient. Respondent superior 13. continuity. . Defamation b. she has committed: a.m. momentarily turning away from a 3 month-old infant she has been weighing. Which of the following is an example of nursing malpractice? a. Assault c. Encourage them to sign the consent form right away d. Listen to their concerns and answer their questions honestly c.m. d.d. Libel c. The infant falls off the scale. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. and discoloration around the umbilicus. Tympanic percussion. High-pitched gurgles head over the right lower quadrant are: a. Horizontal recumbent d. The nurse assists a patient out of bed with the bed locked in position. diaphoresis. This information is documented and reported to the physician and the nursing supervisor. Immobility. Sims c. Vital signs d. Side-lying 20. measurement of abdominal girth. d. If a patient’s blood pressure is 150/96. diarrhea. and avoidance of deep breathing or coughing d. Trendelenburg c. 96 . 15. and palpation 18. palpation. Changing position every 2 hours 16. Supine d. Quiet crying c. Sitting b. A sign of increased bowel motility b.c. Percussions. Genupecterol b. c. The nurse administers the wrong medication to a patient and the patient vomits. For a rectal examination. and severe abdominal pain. Genupectoral d. Prone b. the nurse asks the patient to assume which position? a. A sign of decreased bowel motility c. Guaiac test c. All of the above 21. Decreased blood pressure and heart rate and shallow respirations b. Normal bowel sounds d. Assessment for distention. Standing c. During a Romberg test. tenderness. Auscultation. 54 b. and auscultation d. his pulse pressure is: a. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? a. the patient slips and fractures his right humerus. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? a. A patient is admitted to the hospital with complaints of nausea. vomiting. The correct sequence for assessing the abdomen is: a. Abdominal girth 17. and inspection b. percussion. the patient can be directed to assume which of the following positions? a. A sign of abdominal cramping 19. A patient about to undergo abdominal inspection is best placed in which of the following positions? a. Complete blood count b. Trendelenburg 22. is 99. Radial c. Which findings should be reported? a. Rhythm c. Systolic blood pressure c. A 38-year old patient’s vital signs at 8 a. Rate b. 30. Pulse rate and temperature d. 30. Respiratory rate d. After assessing Mrs. Fever b. Apical pulse 28. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home c.m. d. Which of the following patients is at greatest risk for developing pressure ulcers? a. 23. Sympathetic nervous system stimulation d. are axillary temperature 99. All of the following can cause tachycardia except: a.m. Baseline vital signs b. Exercise c. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula d. Symmetry d. chronic arthritic patient treated with steroids and aspirin b. 150 246 A patient is kept off food and fluids for 10 hours before surgery. Infection b. respiratory rate. Temperature only c. Anxiety d. pulse rate. Femoral 29. Which of the following nursing interventions has the greatest potential for improving this situation? . Dehydration 24. An alert. 88. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. Temperature and respiratory rate 26.6 F (37. Which of the following parameters should be checked when assessing respirations? a. His oral temperature at 8 a. Parasympathetic nervous system stimulation 27.c. Respiratory rate only b. Palpating the midclavicular line is the correct technique for assessing a. the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions.7 C) This temperature reading probably indicates: a. All of the above 25. Apical b.8 F (37. Pedal d. Hypothermia c. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? a.6 C). Paul. “Why are you crying? I didn’t get to the bad news yet” c.a. c. tenacious secretions. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. orthopnea: thick. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing c. d. It’s only temporary” b. “Don’t worry. such as coffee and cola. such as custards. b. 32. b. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Ineffective individual coping to COPD. Lim begins to cry as the nurse discusses hair loss. 37. d. The patient should always feed himself d. 33. The nurse should perform oral hygiene before assisting with feeding. hacking cough. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter. a. Encourage the patient to walk in the hall alone b. Mrs. easier to swallow than water b. c. 31. Less than 30 ml/hour b. The best response would be: a. Kaolin with pectin (Kaopectate) 35. a. Ineffective airway clearance related to thick. b. and a dry hacking cough. 90 ml in 3 hours d. d. c. Beets c. Ineffective airway clearance related to dry. 125 ml in 4 hours 34. Encourage the patient to increase her fluid intake to 200 ml every 2 hours Place a humidifier in the patient’s room. She should notify the physician if the urine output is: a. Certain substances increase the amount of urine produced. tenacious secretions. Which of the following nursing interventions would be appropriate? a. d. 64 ml in 2 hours c. Discourage the patient from walking in the hall for a few more days c. Continue administering oxygen by high humidity face mask Perform chest physiotheraphy on a regular schedule The most common deficiency seen in alcoholics is: Thiamine Riboflavin Pyridoxine Pantothenic acid Which of the following statement is incorrect about a patient with dysphagia? The patient will find pureed or soft foods. An appropriate nursing diagnosis would be: a. the nurse measures his hourly urine output. Caffeine-containing drinks. Accompany the patient for his walk. Urinary analgesics d. Pain related to immobilization of affected leg. These include: a. “Your hair is really pretty” . b. Consuit a physical therapist before allowing the patient to ambulate 36. d. Urinary Tract Infection d. Decreased appetite 46. A semiconscious or over fatigued patient b. Which of the following is the most significant symptom of his disorder? a. A disoriented or confused patient c. Which of the following vascular system changes results from aging? .d. Increased pulse rate and blood pressure c. Lethargy b. After 1 week of hospitalization. Side rails are ineffective b. Side rails are a deterrent that prevent a patient from falling out of bed. Respiratory excitement d. Atheroscleotic changes in the blood vessels b. A prescribed amount of oxygen s needed for a patient with COPD to prevent: a. A patient who cannot care for himself at home d. “I know this will be difficult for you. Gray develops hypokalemia. Side rails should not be used c. Studies have shown that about 40% of patients fall out of bed despite the use of side rails. Young adulthood c. Check to see that the patient is wearing his identification band d. Muscle weakness d. Inhibition of the respiratory hypoxic stimulus 40. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2) b. this has led to which of the following conclusions? a. Increased incidence of gallbladder disease c. Demonstrate the signal system to the patient c. Infancy b. The most common injury among elderly persons is: a. A patient demonstrating symptoms of drugs or alcohol withdrawal 44. Circulatory overload due to hypervolemia c. Pregnancy 39. Inability to concentrate d. Side rails are a reminder to a patient not to get out of bed 43. Muscle irritability 41. Asses the patient’s ability to ambulate and transfer from a bed to a chair b. Sleep disturbances (such as bizarre dreams) c. The most common psychogenic disorder among elderly person is: a. Examples of patients suffering from impaired awareness include all of the following except: a. Which of the following nursing interventions promotes patient safety? a. Hip fracture 45. Childhood d. All of the above 42. An additional Vitamin C is required during all of the following periods except: a. but your hair will grow back after the completion of chemotheraphy” 38. Depression b. Mr. Before rigor mortis occurs. Obtaining a consent of an autopsy b. Placing one pillow under the body’s head and shoulders c. Labeling the corpse appropriately d. Amyotrophic lateral sclerosis (Lou Gerhig’s disease) d. the nurse is responsible for: a. Providing a complete bath and dressing change b. Removing the body’s clothing and wrapping the body in a shroud d. 47.a. Ensuring that the attending physician issues the death certification 49. a major nursing priority is to: a. Withdraw all pain medications ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PRACTICE QUESTIONS . The nurse’s most important legal responsibility after a patient’s death in a hospital is: a. Protect the patient from injury b. d. c. Alzheimer’s disease 48. Parkinson’s disease b. Notifying the coroner or medical examiner c. Insert an airway c. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness. Multiple sclerosis c. Allowing the body to relax normally 50. Increased peripheral resistance of the blood vessels Decreased blood flow Increased work load of the left ventricle All of the above Which of the following is the most common cause of dementia among elderly persons? a. b. Elevate the head of the bed d. the family’s concerns must be addressed before members are asked to sign a consent form. pallor. olives. restlessness. Because transplants are done within hours of death. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. However. she should take action if a problem threatens patient safety. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. 5. Although a new head nurse should initially spend time observing the unit for its strengths and weakness. D. The nurse is responsible for giving the patient breakfast at the scheduled time. Allowing for rest periods decreases the possibility of hypoxia. B. rest and sleep. A platelet count evaluates the number of platelets in the circulating blood volume. Maslow. Tachypnea is rapid respiration characterized by quick.1. cold and clammy skin. tachypnea. these levels must remain within two to two and one half the normal levels. thus improving ventilation. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage. 3. activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs. 6. thirst and confusion). elimination. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. other physiologic needs (including food. The brain-dead patient’s family needs support and reassurance in making a decision about organ donation. Eupnea is normal respiration – quiet. D. C. 10. When a patient develops dyspnea and shortness of breath. 8. 4. his environment. B. and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. his health on the health illness continuum. The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care. urination or heavy prolonged menstruation. Orthopnea is difficulty of breathing except in the upright position. They also seem to gain a greater sense of achievement and esprit de corps. 7. tachycardia. decisions about organ donation must be made as soon as possible. 2. According to this theory. D. who defined a need as a satisfaction whose absence causes illness. considered oxygen to be the most important physiologic need. Mashed potatoes and broiled chicken are low in natural sodium chloride. The physician is responsible for instructing the patient about the test and for writing the order for the test. C. In this case. D. The body of an organ donor is available for burial. blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing. without it. Nurses feel personal satisfaction. water. Studies have shown that patients and nurses both respond well to primary nursing care units. Ham. the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm. hypotension. and without effort. B. and the nursing actions necessary to meet his needs. C. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds. human life could not exist. shelter. shallow breaths. the supervisor is the resource person to approach. . 9. much of it related to positive feedback from the patients. bowel movements. rhythmic. in which the patient lies on his back with his face upward. as well as increased heart rate. Tympanic percussion. A. two or three sounds per minute indicate decreased bowel motility. the standard of care was breached. 17. a 3-month-old infant should never be left unattended on a scale. D. if such action resulted in a serious illness or chronic problem. the fracture was not the result of malpractice. 14. Assessing for distention. C. D. Administering an incorrect medication is a nursing error. the patient kneels and rests his chest on the table. Assault is the unjustifiable attempt or threat to touch or injure another person. measurement of abdominal girth. A. Changes in vital signs may be cause by factors other than blood loss. Abdominal girth is unrelated to blood loss. shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles). To assess for GI tract bleeding when frank blood is absent. and proximal cause (administering the penicillin caused the cerebral damage). 12. Malpractice is defined as injurious or unprofessional actions that harm another.11. In this example. Thus. any act that a nurse performs on the patient against his will is considered assault and battery. appendicitis and peritonitis. 13. tenderness and discoloration around the umbilicus can indicate various bowel-related conditions. they should follow auscultation in abdominal assessment. such as crying. B. Hyperactive sounds indicate increased bowel motility. All of these positions are appropriate for a rectal examination. 15. and guarding or rigidity of the abdominal wall. therefore. Applying a hot water bottle or heating pad to a patient without a physician’s order does not include the three required components. In an abdominal surgery patient. Because percussion and palpation can affect bowel motility and thus bowel sounds. the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. 20. and avoidance of deep breathing or coughing. such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In the Trendelenburg position. The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug). these might include immobility. Assisting a patient out of bed with the bed locked in position is the correct nursing practice. the patient lies on his side. The supine position (also called the dorsal position). A. Written communication that does the same is considered libel. the nurse has two options: She can test for occult blood in vomitus. however. allows for easy access to the abdomen. D. 19. 18. the nurse could be sued for malpractice. Such a patient is unlikely to display emotion. In the lateral position. Oral communication that injures an individual’s reputation is considered slander. 16. Consequently. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. high pitched tinkling bowel sounds can indicate a bowel obstruction. In the prone position. the nurse must observe for objective signs. In the genupectoral (knee-chest) position. An Asian patient is likely to hide his pain. such as cholecystitis. if present. or in stool – through guaiac (Hemoccult) test. the patient lies on his abdomen with his face turned to the side. diaphoresis. Abdominal cramping with hyperactive. It involves professional misconduct. forming a 90 . C. injury (cerebral damage). Battery is the unlawful touching of another person or the carrying out of threatened physical harm. and inspection are methods of assessing the abdomen. C. 8°C). D. Thus. Thus. the patient lies on his left side with the left arm behind the body and his right leg flexed. Blood pressure is typically assessed at the antecubital fossa. Base line vital signs include pulse rate. 30. A normal adult body temperature. the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. 24. 28. rate of impulse conduction and blood flow through the coronary vessels. A. ranges between 97° and 100°F (36. sound. The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth. A. However.degree angle between the torso and upper legs. and blood pressure. 22. 25. then with eyes closed. an axillary temperature is approximately one degree lower and a rectal temperature. D. as measured on an oral thermometer. In the horizontal recumbent position. Because the pedal pulse cannot be detected in 10% to 20% of the population. A slightly elevated temperature in the immediate preoperative or post operative period may result from the lack of fluids before surgery rather than from infection. radial. Age is also a factor. diaphoresis. ease. the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. exercise.1° and 37. 26. D. The quality and efficiency of the respiratory process can be determined by appraising the rate. B. Under normal conditions. so a rate of 88 is normal. . High. which evaluates for sensory or cerebellar ataxia. Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature. 27. mobility. Fever. Hypothermia is an abnormally low body temperature. Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction. and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Anxiety will not cause an elevated temperature. The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case. D. 29. circulation and bladder or bowel control. B. 21. 23. A. an axillary temperature of 99. the patient must stand with feet together and arms resting at the sides—first with eyes open. The resting pulse rate in an adult ranges from 60 to 100 beats/minute. D. rhythm. fifth.6°F (37. temperature. nutrition. and symmetry of respirations. one degree higher. Pressure ulcers are most likely to develop in patients with impaired mental status. activity level. and sympathetic stimulation all increase the heart rate. depth. C. a respiratory rate of 30 would be abnormal. the patient lies on his back with legs extended and hips rotated outward. Thus. dehydration and dyspnea. During a Romberg test.6°C) would be considered abnormal. its absence is not necessarily a significant finding. 31. respiratory rate. or sixth intercostal space. 54. or femoral pulse is abnormal and should be investigated.humidity air and chest physiotherapy help liquefy and mobilize secretions. The need to move the feet apart to maintain this stance is an abnormal finding. In Sims’ position. Absence of the apical. Demonstrating the signal system and providing an opportunity for a return demonstration ensures that the patient knows how to operate the equipment and encourages him to call for assistance when needed. Circulatory overload and respiratory excitement have no relevance to the question. Since about 40% of patients fall out of bed despite the use of side rails. Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patient’s ability to carry out these functions safely. “I know this will be difficult” acknowledges the problem and suggests a resolution to it. D. chronic fatigue. 40. and oral hygiene before eating should be part of the feeding regimen. Fowler’s or semi-Fowler’s position. who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)). they do serve as a reminder that the patient should not get out of bed. Presenting symptoms of hypokalemia ( a serum potassium level below 3. A. A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him. “Don’t worry. which is related to kidney function and inadequate fluid intake. C. Soft foods. 36. The other answers are incorrect interpretations of the statistical data. Waiting to consult a physical therapist is unnecessary. and during pregnancy to supply demands for fetal growth and maternal tissues. can inhibit the hypoxic stimulus for respiration. hacking cough. and shortness of breath are signs of ineffective airway clearance. and cardiac dysrhythmias. 34. Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD). “Your hair is really pretty” offers no consolation or alternatives to the patient. C. however. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. 37. Feeding himself is a long-range expected outcome. orthopnea.. a dry. can color urine red. Beets and urinary analgesics. C. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Thick. Other conditions requiring extra vitamin C include wound healing. D. 35. 39. D. 33. enabling him to face the rest of the world. side rails cannot be said to prevent falls.. 42. B. A urine output of less than 30ml/hour indicates hypovolemia or oliguria. Ineffective individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively. Checking the patient’s identification band verifies the patient’s identity and prevents identification mistakes in drug administration. Accompanying him will offer moral support. Kaopectate is an anti diarrheal medication. Ineffective airway clearance related to dry. infection and stress. tenacious secretions. fever. such as infancy and childhood. Fluids containing caffeine have a diuretic effect. Additional Vitamin C is needed in growth periods. “. A. . Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. A. 38. 41. hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance.32. A patient with dysphagia (difficulty swallowing) requires assistance with feeding.” offers some relief but doesn’t recognize the patient’s feelings. such as pyridium. so he should not walk alone. D.5 mEq/liter) include muscle weakness.I didn’t get to the bad news yet” would be inappropriate at any time. C. 49. 2. 3. MATERNAL AND CHILD HEALTH NURSING PRACTICE QUESTIONS WITH RATIONALE 1. progressive. 44. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. including those necessary for respiration. These changes. D. The other nursing actions may be necessary but are not a major priority. eventually results in atrophy of all the muscles. The other answers are diseases that can occur in the elderly from physiologic changes. and irritability. but he is responsible for issuing it.s disease. Other symptoms include diminished memory. Alzheimer. a progressive. Amyotrophic lateral sclerosis. Hip fracture. a disease marked by progressive degeneration of the neurons. D. The nurse must place a pillow under the decreased person’s head and shoulders to prevent blood from settling in the face and discoloring it. A. sometimes known as senile dementia of the Alzheimer’s type or primary degenerative dementia. disinterest in appearance. apathy. the most common psychogenic disorder among elderly persons. B. or biochemical factors 46. Depression typically begins before the onset of old age and usually is caused by psychosocial. usually results from osteoporosis. Sleep disturbances. degenerative disease involving demyelination of the nerve fibers. 4. which leads to increased peripheral resistance and decreased blood flow. Multiple sclerosis. and dysphonia. Before wrapping the body in a shroud. withdrawal. the nurse places a clean gown on the body and closes the eyes and mouth. When assessing the adequacy of sperm for conception to occur. 48. she is not legally responsible for performing these functions. and degenerative disease of the brain whose etiology is still unknown. irreversible. Ensuring the patient’s safety is the most essential action at this time.43. She is required to bathe only soiled areas of the body since the mortician will wash the entire body. the most common injury among elderly persons. A. genetic. 50. muscle rigidity. She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patient’s death. he may simply have some degree of immobility. usually begins in young adulthood and is marked by periods of remission and exacerbation. which of the following is the most useful criterion? Sperm count Sperm motility Sperm maturity Semen volume . inability to concentrate and decreased appetite are symptoms of depression. in turn. 47. is an insidious. 1. Parkinson’s disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors. Aging decreases elasticity of the blood vessels. C. 45. A patient who cannot care for himself at home does not necessarily have impaired awareness. hypokinesis. however. increase the work load of the left ventricle. The attending physician may need information from the nurse to complete the death certificate. D. dysphagia. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester? Dysuria Frequency Incontinence Burning Heartburn and flatulence. breast. 2 1. the nurse would explain that this is most probably the result of which of the following? Thrombophlebitis Pregnancy-induced hypertension Pressure on blood vessels from the enlarging uterus The force of gravity pulling down on the uterus Cervical softening and uterine souffle are classified as which of the following? Diagnostic signs .2. When discussing the situation with the nurse. 3. 3. 4. 3. are most likely the result of which of the following? Increased plasma HCG levels Decreased intestinal motility Decreased gastric acidity Elevated estrogen levels On which of the following areas would the nurse expect to observe chloasma? Breast. and nipples Chest. 2. one partner states. forehead. 4. 3. “We know several friends in our age group and all of them have their own child already. Ineffective family coping related to infertility. Why can’t we have one?”. leg veins. A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. The nurse’s explanation is based on which of the following as the cause? The large size of the newborn Pressure on the pelvic muscles Relaxation of the pelvic joints Excessive weight gain Which of the following represents the average amount of weight gained during pregnancy? 12 to 22 lb 15 to 25 lb 24 to 30 lb 25 to 40 lb When talking with a pregnant client who is experiencing aching swollen. Which of the following would be the most pertinent nursing diagnosis for this couple? Fear related to the unknown Pain related to numerous procedures. 3. areola. 4. and legs Abdomen. 4. 2. 3. 1. 3. 4. 4. 2 1. common in the second trimester. 4. neck. and thighs Cheeks. 2 1. and nose A pregnant client states that she “waddles” when she walks. 2 1. 2. 2. 2 1. arms. 2. 2. 2 1. Self-esteem disturbance related to infertility. 2 1. 2. fear. fetal development. narcissism 2. A spontaneous abortion or a missed abortion is impending 2 FHR can be auscultated with a fetoscope as early as which of the following? 1. October 12 2 Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of the LMP is unknown? 1. Presumptive signs 3. Positive signs 2 Which of the following would the nurse identify as a presumptive sign of pregnancy? 1. and unattractiveness 3. egocentrism. Nausea and vomiting 3. extroversion 4. Uterus at the xiphoid 3. The incidence of allergies increases due to maternal antibodies 3. and nutrition? 1. There is a greater chance for error during preparation 2 Which of the following would cause a false-positive result on a pregnancy test? 1. Skin pigmentation changes 4. The test was performed too early or too late in the pregnancy 3. First trimester 3. Her EDD should be which of the following? 1. Prepregnant period 2. 20 weeks gestation 2 A client LMP began July 5.2. fantasies 2 During which of the following would the focus of classes be mainly on physiologic changes. 15 weeks gestation 4. The father may resent the infant’s demands on the mother’s body 4. Introversion. Probable signs 4. Uterus in the pelvis 2. Uterus at the umbilicus . Hegar sign 2. passivity. Positive serum pregnancy test 2 Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester? 1. The test was performed less than 10 days after an abortion 2. Anxiety. Second trimester 4. 10 weeks gestation 3. during pregnancy. The urine sample was stored too long at room temperature 4. Third trimester 2 Which of the following would be disadvantage of breast feeding? 1. Uterus in the abdomen 4. April 12 4. clumsiness. sexuality. March 28 3. Involution occurs more rapidly 2. Awkwardness. Ambivalence. January 2 2. 5 weeks gestation 2. 3. 2. Adverse reactions may include maternal hypotension. 2. 2 1. 3. 4. 4. and lack of an antagonist make them generally inappropriate during labor. 3.2 1. 4. 3. They rapidly transfer across the placenta. 2 Which of the following danger signs should be reported promptly during the antepartum period? Constipation Breast tenderness Nasal stuffiness Leaking amniotic fluid Which of the following prenatal laboratory test values would the nurse consider as significant? Hematocrit 33. Assess uterine contractions every 30 minutes. causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. 3. 2. allergic or toxic reaction or partial or total respiratory failure Which of the following nursing interventions would the nurse perform during the third stage of labor? Obtain a urine specimen and other laboratory tests. which of the following cardinal movements occur? .5% Rubella titer less than 1:8 White blood cells 8. These drugs readily cross the placental barrier. 2 1. 3. 2. 3.000/mm3 One hour glucose challenge test 110 g/dL Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor? Occurring at irregular intervals Starting mainly in the abdomen Gradually increasing intervals Increasing intensity with walking During which of the following stages of labor would the nurse assess “crowning”? First stage Second stage Third stage Fourth stage Barbiturates are usually not given for pain relief during active labor for which of the following reasons? The neonatal effects include hypotonia. Suctioning with a bulb syringe Obtaining an Apgar score Inspecting the newborn’s umbilical cord Immediately before expulsion. 2 1. and reluctance to feed for the first few days. hypothermia. Coach for effective client pushing Promote parent-newborn interaction. 2 1. 2. 4. generalized drowsiness. 4. Which of the following actions demonstrates the nurse’s understanding about the newborn’s thermoregulatory ability? Placing the newborn under a radiant warmer. 2. 4. 2. 4. 2 1. 2 1. 80 beats per minute 2. Umbilical vein 2. which of the following ranges would be considered normal if the newborn were sleeping? 1. Blink. 4. cough. rooting. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise. Foramen ovale 3. 100 beats per minute 3. the anterior closes at 8 to 12 weeks. swallowing. Flexion 3. the posterior is diamond shaped. Excess iron 2 When assessing the newborn’s heart rate.1. Stepping. 140 beats per minute 2 Which of the following is true regarding the fontanels of the newborn? 1. The anterior is triangular shaped. cough. 3. 120 beats per minute 4. cough. The posterior closes at 18 months. Uric acid crystals 3. 2. Bilirubin 4. sneeze. Ductus venosus 2 Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn? 1. gag 3. or corner of mouth is touched. 2 Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood? 1. The newborn turns the head in the direction of stimulus. Descent 2. which of the following structures connects the right and left auricles of the heart? 1. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface 2 Which of the following statements best describes hyperemesis gravidarum? . The anterior is large in size when compared to the posterior fontanel. and cough 4. Rooting. Extension 4. opens the mouth. lip. and begins to suck when cheek. 4. and gag 2. the posterior appears sunken. and sneeze 2 Which of the following describes the Babinski reflex? 1. Mucus 2. sneeze. Blink. The anterior is bulging. Ductus arteriosus 4. blink. The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot. 2. 3. External rotation 2 Before birth. Severe nausea and vomiting leading to electrolyte. metabolic. 3. 4. 2 1. 2 1. and nutritional imbalances in the absence of other medical problems. 3. 2 1. 2 1. 4. 2 1. 4. painless vaginal bleeding Concealed or external dark red bleeding Palpable fetal outline Soft and nontender abdomen Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy. 3. 3. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding Which of the following would the nurse identify as a classic sign of PIH? Edema of the feet and ankles Edema of the hands and face Weight gain of 1 lb/week Early morning headache In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests? Threatened Imminent Missed Incomplete Which of the following factors would the nurse suspect as predisposing a client to placenta previa? Multiple gestation Uterine anomalies Abdominal trauma Renal or vascular disease Which of the following would the nurse assess in a client experiencing abruptio placenta? Bright red. 3. 3. 3. metabolic.1. 2. 4. 4. 4. and nutritional imbalances in the absence of other medical problems. 4. 2. 2. usually with severe hemorrhage? Placenta previa Ectopic pregnancy Incompetent cervix Abruptio placentae Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor? Weak contraction prolonged to more than 70 seconds Tetanic contractions prolonged to more than 90 seconds Increased pain with bright red vaginal bleeding Increased restlessness and anxiety When preparing a client for cesarean delivery. which of the following key concepts should be considered when implementing nursing care? . 2 Severe anemia leading to electrolyte. 2. 2 1. 2. 2. 2. 2 1. 4. 2. 2 1. 2 1. 3. 2. 2. 4. and kind of anesthetics Which of the following best describes preterm labor? Labor that begins after 20 weeks gestation and before 37 weeks gestation Labor that begins after 15 weeks gestation and before 37 weeks gestation Labor that begins after 24 weeks gestation and before 28 weeks gestation Labor that begins after 28 weeks gestation and before 40 weeks gestation When PROM occurs. 2. 2. which of the following would be the priority? Limiting hypovolemic shock Obtaining blood specimens Instituting complete bed rest Inserting a urinary catheter Which of the following is the nurse’s initial action when umbilical cord prolapse occurs? Begin monitoring maternal vital signs and FHR Place the client in a knee-chest position in bed Notify the physician and prepare the client for delivery Apply a sterile warm saline dressing to the exposed cord Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage? More than 200 ml More than 300 ml More than 400 ml More than 500 ml Which of the following is the primary predisposing factor related to mastitis? . 3. 4. 2. 2 Instruct the mother’s support person to remain in the family lounge until after the delivery Arrange for a staff member of the anesthesia department to explain what to expect postoperatively Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth Explain the surgery. PROM removes the fetus most effective defense against infection Nursing care is based on fetal viability and gestational age. 2 1. 4. 3. 2. 4.1. 3. 3. PROM is associated with malpresentation and possibly incompetent cervix Which of the following factors is the underlying cause of dystocia? Nurtional Mechanical Environmental Medical When uterine rupture occurs. 2 1. which of the following provides evidence of the nurse’s understanding of the client’s immediate needs? The chorion and amnion rupture 4 hours before the onset of labor. 4. 4. 2 1. expected outcome. 3. 3. fever and suprapubic pain Dehydration. 2. frequency. occurring 2 weeks after delivery Muscle pain the presence of Homans sign. 2 1. and flank pain Nocturia. 2 1. 4. flank pain nausea. 2. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts Endemic infection occurring randomly and localizing in the periglandular connective tissue Temporary urinary retention due to decreased perception of the urge to avoid Breast injury caused by overdistention. 2 1. 3. tenderness and redness along the vein Chills. 4. dysuria. 3. 4. fever. hematuria. 4. stasis. suprapubic pain. chills. fever. 3. and frequency Which of the following best reflects the frequency of reported postpartum “blues”? Between 10% and 40% of all new mothers report some form of postpartum blues Between 30% and 50% of all new mothers report some form of postpartum blues Between 50% and 80% of all new mothers report some form of postpartum blues Between 25% and 70% of all new mothers report some form of postpartum blues For the client who is using oral contraceptives. and swelling in the affected limb Chills. chills. dysuria. and pain occurring 10 to 14 days after delivery Which of the following are the most commonly assessed findings in cystitis? Frequency. 2 1. 4. the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following? Decrease the incidence of nausea Maintain hormonal levels Reduce side effects Prevent drug interactions . 2. chills. 3. urgency. and fever High fever. malaise.1. 2. 2. 2. hypertension. 3. urgency dysuria. nausea. and cracking of the nipples Which of the following best describes thrombophlebitis? Inflammation and clot formation that result when blood components combine to form an aggregate body Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels Inflammation and blood clots that eventually become lodged within the femoral vein Inflammation of the vascular endothelium with clot formation on the vessel wall Which of the following assessment findings would the nurse expect if the client develops DVT? Midcalf pain. stiffness. vomiting. 4. dehydration. 2 1. 3. October 21 3. Female condom 3. Nulliparous woman 3. 1 pound per week for 40 weeks 3. Postpartum client 53 A client in her third trimester tells the nurse. Rhythm method 53 For which of the following clients would the nurse expect that an intrauterine device would not be recommended? 1. a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks. November 7 4. Using Nagele’s rule. recommendations for which of the following contraceptive methods would be avoided? 1. “I had a son born at 38 weeks gestation. “I’m constipated all the time!” Which of the following should the nurse recommend? 1. Laxatives 3. Diaphragm 2. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections? 1. Condoms 4. Spermicides 2. Daily enemas 2. G2 T2 P0 A0 L2 2. 10 pounds per trimester 2. ½ pound per week for 40 weeks 4. A total gain of 25 to 30 pounds 53 The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Increased fiber intake 4. Promiscuous young adult 4. Woman over age 35 2. When preparing a woman who is 2 days postpartum for discharge. the nurse determines her EDD to be which of the following? 1. Decreased fluid intake 53 Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy? 1. December 27 53 When taking an obstetrical history on a pregnant client who states. Oral contraceptives 4. G3 T1 P1 A0 L2 52. . Diaphragm 3. Vasectomy 53.” the nurse should record her obstetrical history as which of the following? 1. September 27 2.When teaching a client about contraception. which of the following should the nurse do first? 1. which of the following instructions would be the priority? 1. Dietary intake 53 A client 12 weeks’ pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Hand/face edema 4. Administer analgesia 3. Depression 3. the nurse would use which of the following? 1. Knowledge Deficit 4. Encourage her to wear a nursing brassiere 4. Glucosuria 2. Administer a narcotic before breast feeding 3. Tell her to breast feed more frequently 2. Risk for infection 2. Fetoscope placed midway between the umbilicus and the xiphoid process 4. Threatened abortion 2. The nurse would document these findings as which of the following? 1. Imminent abortion 3. Complete abortion 4. Assist her to urinate 53 Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples? 1. Anticipatory Grieving 53 Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus and midline. Ambulate her in the hall 4. Assess the vital signs 2. Dietary intake 2. Missed abortion 53 Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy? 1. Stethoscope placed midline at the umbilicus 2.3. Which of the following would be the priority when assessing the client? 1. G3 T2 P0 A0 L2 4. Use soap and water to clean the nipples . Doppler placed midline at the suprapubic region 3. Medication 3. Speculum examination reveals 2 to 3 cms cervical dilation. External electronic fetal monitor placed at the umbilicus 53 When developing a plan of care for a client newly diagnosed with gestational diabetes. Pain 3. Glucose monitoring 53 A client at 24 weeks gestation has gained 6 pounds in 4 weeks. G4 T2 P1 A1 L2 53 When preparing to listen to the fetal heart rate at 12 weeks’ gestation. Exercise 4. A dark red discharge on a 2-day postpartum client 2. Dehydration . Covering the infant’s head with a knit stockinette 53 A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following? 1.4ºF. Increased intracranial pressure 53 During the first 4 hours after a male circumcision. and not descending as normally expected.53 The nurse assesses the vital signs of a client. Placing crib close to nursery window for family viewing 4. A pink to brownish discharge on a client who is 5 days postpartum 3. Discomfort 4. assessing for which of the following is the priority? 1. Promoting comfort and restoration of health 2. A bright red discharge 5 days after delivery 53 A postpartum client has a temperature of 101. Which of the following should the nurse do first? 1. Almost colorless to creamy discharge on a client 2 weeks after delivery 4. Report the temperature to the physician 2. Assess the uterus for firmness and position 4. pulse 100 weak. Determine the amount of lochia 53 The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Breasts 3. Talipes equinovarus 2. Lochia 2. temperature 100. Exploring the emotional status of the family 3.4ºF. Placing infant under radiant warmer after bathing 2. Which of the following assessments would warrant notification of the physician? 1. Congenital hypothyroidism 4. Facilitating safe and effective self-and newborn care 4. Incision 4. Hemorrhage 3. Fractured clavicle 3. thready. Recheck the blood pressure with another cuff 3. Infection 2. R 20 per minute. Which of the following should the nurse assess next? 1. Teaching about the importance of family planning 53 Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn? 1. Urine 53 Which of the following is the priority focus of nursing practice with the current early postpartum discharge? 1. Covering the scale with a warmed blanket prior to weighing 3. 4 hours’ postpartum that are as follows: BP 90/60. with a uterus that is tender when palpated. remains unusually large. Which of the following should the nurse do? 1. ‘Alcohol helps it dry and kills germs” 3. “A decrease in material hormones present before birth causes enlargement. It could be a malignancy” 4. 6 ounces 53 The postterm neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following? 1. From the fundus to the umbilicus 53 A client with severe preeclampsia is admitted with of BP 160/110. nostril flaring. “The tissue has hypertrophied while the baby was in the uterus” 53 Immediately after birth the nurse notes the following on a male newborn: respirations 78. Elimination problems 53 When measuring a client’s fundal height. Suction the infant’s mouth and nares 4. Call the assessment data to the physician’s attention 2. Which of the following statements by the mother indicates effective teaching? 1. Recognize this as normal first period of reactivity 53 The nurse hears a mother telling a friend on the telephone about umbilical cord care. 4 ounces 4. From the xiphoid process to the umbilicus 2. and grunting at the end of expiration. Respiratory problems 2. From the symphysis pubis to the fundus 4. 2 ounces 2. “Daily soap and water cleansing is best” 2. Which of the following would be most important to include in the client’s plan of care? 1. Seizure precautions . “What’s wrong with my son’s breasts? Why are they so enlarged?” Whish of the following would be the best response by the nurse? 1. “An antibiotic ointment applied daily prevents infection” 4. and severe pitting edema. “The breast tissue is inflamed from the trauma experienced with birth” 2.53 The mother asks the nurse. Start oxygen per nasal cannula at 2 L/min. “You should discuss this with your doctor. “He can have a tub bath each day” 53 A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional needs? 1. Gastrointestinal problems 3. From the symphysis pubis to the xiphoid process 3. apical hearth rate 160 BPM. which of the following techniques denotes the correct method of measurement used by the nurse? 1. Daily weights 2. proteinuria.” 3. 3 ounces 3. 3. mild intercostal retractions. Integumentary problems 4. the nurse would select which of the following sites as appropriate for the injection? 1. the hormonal stimulation of the embryo that must occur involves which of the following? 1. Fetal kicking felt by the client 4. “When the discharge has stopped and the incision is healed. Right lateral positioning 4.” 4. Bartholin’s gland 53 To differentiate as a female. Gluteus maximus muscle 53 When performing a pelvic examination. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water 2. The nurse documents this as which of the following? 1.” 3. Vastus lateralis muscle 4. Anterior femoris muscle 3. Skene’s gland 4. Goodell’s sign 4. The nurse would document this as enlargement of which of the following? 1. Avoiding the intake of liquids in the morning hours 4. “After your 6 weeks examination. Stress reduction 53 A postpartum primipara asks the nurse. “When can we have sexual intercourse again?” Which of the following would be the nurse’s best response? 1. Decrease in maternal androgen secretion 3.” 2. Secretion of androgen by the fetal gonad 4. Secretion of estrogen by the fetal gonad 53 A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Braxton-Hicks sign 2. Which of the following client interventions should the nurse question? 1. Increase in maternal estrogen secretion 2. Clitoris 2. Passive movement of the unengaged fetus 3. Palpable contractions on the abdomen 2. “Anytime you both want to. Enlargement and softening of the uterus 53 During a pelvic exam the nurse notes a purple-blue tinge of the cervix. Deltoid muscle 2. Eating six small meals a day instead of thee large meals 53 The nurse documents positive ballottement in the client’s prenatal record.” 53 When preparing to administer the vitamin K injection to a neonate. “As soon as choose a contraceptive method.3. the nurse observes a red swollen area on the right side of the vaginal orifice. Parotid gland 3. McDonald’s sign . Eating a few low-sodium crackers before getting out of bed 3. Chadwick’s sign 3. The nurse understands that this indicates which of the following? 1. Eliminate pain and give the expectant parents something to do 2.” 53 The nurse understands that the fetal head is in which of the following positions with a face presentation? 1. In the lower-right maternal abdominal quadrant 4. Cervical dilation 53 Which of the following would be the nurse’s most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa? 1. The nurse interprets this to be the result of which of the following? 1. Facilitate relaxation. Above the maternal umbilicus and to the left of midline 53 The amniotic fluid of a client has a greenish tint. “You need a cesarean to prevent hemorrhage. In the lower-left maternal abdominal quadrant 3. Partially flexed 53 With a fetus in the left-anterior breech presentation. Partially extended 4.” 4. Above the maternal umbilicus and to the right of midline 2. Completely flexed 2. Preparing for a cesarean section for failure to progress 4. Eliminate pain so that less analgesia and anesthesia are needed 53 After 4 hours of active labor. Maternal vital sign 2. Completely extended 3. Obtaining an order to begin IV oxytocin infusion 2. the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following? 1.” 2. “The placenta is covering the opening of the uterus and blocking your baby. bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided? 1. Administering a light sedative to allow the patient to rest for several hour 3. possibly reducing the perception of pain 4.” 3. the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. “The placenta is covering most of your cervix. Lanugo . Fetal heart rate 3. “You will have to ask your physician when he returns. Contraction monitoring 4. Which of the following would the nurse anticipate doing? 1. Reduce the risk of fetal distress by increasing uteroplacental perfusion 3.53 During a prenatal class. Increasing the encouragement to the patient when pushing begins 53 A multigravida at 38 weeks’ gestation is admitted with painless. the nurse would expect the fetal heart rate would be most audible in which of the following areas? 1. Zygote 4. the nurse understands that the underlying mechanism is due to variations in which of the following phases? 1. Nurse-midwifery 3. Testosterone 3. Prolapsed umbilical cord 53 When describing dizygotic twins to a couple. Menstrual phase 2. recovery. Pica 4. Meconium 4. Hydramnio 3. The nurse should be particularly alert for which of the following? 1. Two ova fertilized by separate sperm 2. Each ova with the same genotype 4. on which of the following would the nurse base the explanation? 1. Symphysis pubis 2. which of the following would the nurse include as being produced by the Leydig cells? 1. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth? 1. Quickening 2. Vernix 53 A patient is in labor and has just been told she has a breech presentation. Sharing of a common chorion 53 Which of the following refers to the single cell that reproduces itself after conception? 1. Pubic arch 53 When teaching a group of adolescents about variations in the length of the menstrual cycle. Which of the following was an outgrowth of this concept? 1. Ischial spines 4. Follicle-stimulating hormone 2. Labor. Blastocyst 3. Leuteinizing hormone . Trophoblast 53 In the late 1950s. Proliferative phase 3. Prepared childbirth 53 A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Chromosome 2. postpartum (LDRP) 2. Sacral promontory 3. Ophthalmia neonatorum 3. Secretory phase 4. Ischemic phase 53 When teaching a group of adolescents about male hormone production.2. Clinical nurse specialist 4. delivery. Sharing of a common placenta 3. Increased food intake owing to age 2. Perform an intensive neurologic examination. While performing physical assessment of a 12 month-old. Multiple-piece puzzle . so you don’t spoil her” 2. Guilt 4. Bowlegged posture 4. 2. Mistrust 2. the nurse notes that the infant’s anterior fontanelle is still slightly open. Guilt 4. 2 months 3. the nurse notes a characteristic protruding abdomen. “If you leave her alone she will learn how to cry herself to sleep” 102 When assessing an 18-month-old. which of the following indicates the earliest age at which this should be done? 1. Shame 3. Which of the following would explain the rationale for this finding? 1. A colorful busy box 102 The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. A push-pull wooden truck 4. give her a bottle” 4. 1 month 2. Inferiority 102 Which of the following toys should the nurse recommend for a 5-month-old? 1. A big red balloon 2. Linear growth curve 102 If parents keep a toddler dependent in areas where he is capable of using skills. Underdeveloped abdominal muscles 3. 3 months 4. 102. you won’t spoil her this way” 3. A teddy bear with button eyes 3. Mistrust 2. Notify the physician immediately because there is a problem. “Babies need to be held and cuddled. “ Let her cry for a while before picking her up. Inferiority 102 Which of the following is an appropriate toy for an 18-month-old? 1.Gonadotropin releasing hormone 101. Shame 3. Perform an intensive developmental examination. Do nothing because this is a normal finding for the age. Which of the following would be the nurse’s best response? 1. When teaching a mother about introducing solid foods to her child. the toddle will develop a sense of which of the following? 1. 3. Which of the following is the nurse’s most appropriate action? 1. “Crying at this age means the baby is hungry. 4 months 102 The infant of a substance-abusing mother is at risk for developing a sense of which of the following? 1. 4. Preference to eat alone 3. Ordering dolls according to size 3. when voiced by the parents following a teaching session about the characteristics of school-age cognitive development would indicate the need for additional teaching? 1. Wooden puzzle 4. Verbalizes desire to go to the bathroom 102 When teaching parents about typical toddler eating patterns. which of the following should be included? 1. “Allow him to fall asleep in your room. Large blocks 2. Reaction formation 4. Repression 3. Dress-up clothes 3. Developing plans for the future 102 A hospitalized schoolager states: “I’m not afraid of this place.Miniature cars Finger paints Comic book When teaching parents about the child’s readiness for toilet training. Big wheels 102 Which of the following activities. Considering simple problem-solving options 4. Regression 2. “Tell him that you will lock him in his room if he gets out of bed one more time. Increase in appetite 102 Which of the following suggestions should the nurse offer the parents of a 4year-old boy who resists going to bed at night? 1.” 3.” 102 When providing therapeutic play. Demonstrates dryness for 4 hours 2. which of the following toys would best promote imaginative play in a 4-year-old? 1. “Read him a story and allow him to play quietly in his bed until he falls asleep. 102 . Demonstrates ability to sit and walk 3. which of the following signs should the nurse instruct them to watch for in the toddler? 1. 4.” This statement is most likely an example of which of the following? 1.” 4.” 2. Rationalization 2. Has a new sibling for stimulation 4. then move him to his own bed. 3. I’m not afraid of anything. Collecting baseball cards and marbles 2. “Encourage active play at bedtime to tire him out so he will fall asleep faster. Consistent table manners 4. Food “jags” 2. At age 13 102 The adolescent’s inability to develop a sense of who he is and what he can become results in a sense of which of the following? 1. “This is probably the only concern he has about his body. Would you feel comfortable discussing your cleansing method?” 102 . A female’s first menstruation or menstrual “periods” 2. In a month from now 2. So don’t worry about it or the time he spends on it. Guilt 3.” 102 Which of the following skills is the most significant one learned during the schoolage period? 1. In a year from now 3. dominates the bathroom by using the mirror all the time. Reading 4.” 2. At age 10 4. Sorting 102 A child age 7 was unable to receive the measles.” 3. Collecting 2. Inferiority 4. “You appear to be keeping your face well washed. “Schoolagers are more susceptible to home hazards than are younger children. The onset of uterine maturation or peak growth 102 A 14-year-old boy has acne and according to his parents.” 2. The entire menstrual cycle or from one “period” to another 4. “Schoolagers are unable to understand potential dangers around them. Ordering 3. So they spend a lot of time grooming.After teaching a group of parents about accident prevention for schoolagers. “Schoolargers are less subject to parental control than are younger children. The first year of menstruation or “period” 3.” 4. Shame 2. mumps. “A teen may develop a poor self-image when experiencing acne. “Teenagers are anxious about how their peers perceive them. Do you feel this way sometimes?” 4. Role diffusion 102 Which of the following would be most appropriate for a nurse to use when describing menarche to a 13-year-old? 1. “Schoolagers are more active and adventurous than are younger children.” 3. and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine? 1. Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents? 1. which of the following statements by the group would indicate the need for more teaching? 1. Sharing crayons to color separate pictures 2. Most teenage pregnancies are planned. Rolling from front to back 4. 4. 3. the nurse would keep in mind which of the following? 1. The child is exhibiting normal pre-school curiosity 2. Ineffective functioning of the Eustachian tubes 3. 2. The incidence of teenage pregnancies is increasing. Plugging of the Eustachian tubes with food particles 4.” 102 When developing a teaching plan for a group of high school students about teenage pregnancy.” 4. 102 When assessing a child with a cleft palate. “We’ll try to encourage him to talk about his problem. Encouraging adequate intake of iron-rich foods 3.” 3. “We’ll discuss possible solutions with him and his counselor. A strong parachute reflex 3. Sitting near each other while playing with separate dolls 4. Playing a board game with a nurse 3. Assisting with coping with chronic illness 102 . 9 months 4. 12 months 102 Which of the following best describes parallel play between two toddlers? 1. A strong Moro reflex 2. 102 Which of the following statements by the parents of a child with school phobia would indicate the need for further teaching? 1. The risk for complications during pregnancy is rare. “We’ll work with his teachers and counselors at school. Lifting of head and chest when prone 102 By the end of which of the following would the nurse most commonly expect a child’s birth weight to triple? 1. “We’ll keep him at home until phobia subsides.Which of the following should the nurse suspect when noting that a 3-year-old is engaging in explicit sexual behavior during doll play? 1. Instituting infection control precautions 2. 7 months 3. which of the following characteristics would be expected? 1.” 2. Denial of the pregnancy is common early on. The child does not know how to play with dolls 4. the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following? 1. Associated congenital defects of the middle ear. The child is probably developmentally delayed. 102 While performing a neurodevelopmental assessment on a 3-month-old infant. Lowered resistance from malnutrition 2. The child is acting out personal experiences 3. 4 months 2. Sharing their dolls with two different nurses 102 Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia? 1. Notify the physician immediately 4. Notify the child’s physician immediately. Schedule a follow-up visit to check for more bruises. Seizure disorder 102 Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees. Displacement 2. Reasons for subsequent rash 4. Measures to control subsequent diarrhea 102 Which of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trunk of an 18month-old child during a home visit? 1. 4. Don nothing because this is a normal finding in a toddler. Measures to reduce fever 2. Medicate him with acetaminophen. Have him lie down and rest after encouraging fluids. Susceptibility to respiratory infection 2. inspiratory stridor. Increased fluid intake 4. Notify the physician immediately and prepare for intubation. Examine his throat and perform a throat culture 4. tetanus. Repression 4. 2. 3. who is learning forward and drooling? 1. 3. Report the child’s condition to Protective Services immediately. you have no idea how to care for my sick child”? 1. Auscultate his lungs and place him in a mist tent. and restlessness. 2. 102 . Projection 3. and pertussis injection? 1. A shorter urethra in females 2. 2. Need for dietary restrictions 3. would indicate to the nurse that she understands home care instructions following the administration of a diphtheria.Administering medications via IM injections Which of the following information. “You idiot. 102 Which of the following is being used when the mother of a hospitalized child calls the student nurse and states. Ingestion of acidic juices 102 Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome? 1. 102 Which of the following would the nurse need to keep in mind as a predisposing factor when formulating a teaching plan for child with a urinary tract infection? 1. Psychosis 102 Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? 1. Frequent vomiting and diarrhea 4. Bleeding tendencies 3. Frequent emptying of the bladder 3. when voiced by the mother. Lack of speech 3. Transverse palmar crease 3. In an infant seat 4. Large nose 4. Slow to feed self 2. 2 months 3. Supine 2. Prone 3. 102 Which of the following is characteristic of a preschooler with mid mental retardation? 1. the nurse should position the child in which of the following positions? 1. 12 months 102 When discussing normal infant growth and development with parents. Immediate gratification is necessary to develop initiative. Locomotion 4. the nurse would be alert that which of the following will most likely be compromised? 1. At birth 2. Small tongue 2. GI function 102 When providing postoperative care for the child with a cleft palate. The child can use complex reasoning to think out situations. The child engages in competitive types of play 4. 102 . Push-pull toys 2. On the side 3. 4. Restricted joint movement 102 While assessing a newborn with cleft lip. Gait disability 102 Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant? 1. Sucking ability 2. which of the following toys would the nurse suggest as most appropriate for an 8-monthold? 1. Large blocks 4. Marked motor delays 4. Mobile 102 Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child? 1. Fear of body mutilation is a common preschool fear 3. Respiratory status 3. Rattle 3. 6 months 4.Release the traction Monitor him every 5 minutes At which of the following ages would the nurse expect to administer the varicella zoster vaccine to child? 1. 2. Nothing. Regurgitation 2. Abdominal wall defect 102 When assessing a child for possible intussusception. Administer antidiarrheal medications 3. Fluid volume deficit 2.While assessing a child with pyloric stenosis. Intussusception 4. this is characteristic of Hirschsprung disease 102 A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following? 1. Altered nutrition: less than body requirements 4. Projectile vomiting 4. Milk 3. Lethargy 3. Weight 102 Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following? 1. Altered oral mucous membranes 102 Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? 1. Pain pattern 102 . Respiratory distress 2. Risk for aspiration 3. Monitor child ever 30 minutes 4. Celiac disease 3. Watery diarrhea 4. Uterine 4. Chicken 102 Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection? 1. which of the following would be least likely to provide valuable information? 1. Rice 2. Hirschsprung disease 2. “Currant jelly” stools 102 Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)? 1. the nurse is likely to note which of the following? 1. Steatorrhea 3. Stool inspection 2. Notify the physician immediately 2. Stools 3. Vomiting 2. Weight gain 102 Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea? 1. Wheat 4. Family history Abdominal palpation .3. 4. Presumptive signs of pregnancy are subjective signs. serum laboratory tests. skin pigmentation changes. Although all of the factors listed are important. the nursing diagnosis of self-esteem disturbance is most appropriate. A weight gain of 25 to 40 lb is considered excessive. areola. breasts – 3 lb. Other probable signs include Hegar sign. B. Dysuria. legs. Fear. The average amount of weight gained during pregnancy is 24 to 30 lb. sperm motility is the most significant criterion when assessing male infertility. excessive fatigue. Subsequently. 5. edema and varicose vein formation may occur. which is enlargement and softening of the uterus. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. and a positive serum pregnancy test are considered probably signs. which are strongly suggestive of pregnancy. Weight gain has no effect on gait. whereas a weight gain of 15 to 25 lb is marginal. Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities.5 lb. Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. breast tenderness and changes. Hegar sign. urinary frequency. D. Thrombophlebitis is an inflammation of the veins due to thrombus formation. changes in skin pigmentation. Decrease intestinal motility would most likely be the cause of constipation and bloating. B. arms. 9. pain. 6. 8. also called the mask of pregnancy. D. C. nipples. trimester. Based on the partner’s statement. Sperm count. and increased blood volume – 2 to 4 lb. or thighs. Probable signs are objective findings that strongly suggest pregnancy. Of the signs listed. 4. It is not seen on the breasts. Piskacek sign. abdomen.5 lb. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. 10. C. Pregnancy-induced hypertension is not associated with these symptoms. . incontinence. nausea and vomiting. HCG levels increase in the first.5 lb. This weight gain consists of the following: fetus – 7. only nausea and vomiting are presumptive signs. is an irregular hyperpigmented area found on the face. B.ANSWER AND RATIONALE 1. During the second trimester. can cause heartburn and flatulence. but they are not as significant sperm motility. 7. and ultrasonic evidence of a gestational sac. Estrogen levels decrease in the second trimester. placenta and membrane – 1. C. and ineffective family coping also may be present but as secondary nursing diagnoses. chest. amniotic fluid – 2 lb. Thus. uterus – 2. C. and burning are symptoms associated with urinary tract infections. neck. extravascular fluid and fat – 4 to 9 lb. During pregnancy. Changes in posture are related to the growing fetus. 3. hormonal changes cause relaxation of the pelvic joints. not the second. Presumptive signs are subjective signs and include amenorrhea. A gain of 12 to 22 lb is insufficient. which is softening of the lower uterine segment. and semen volume are all significant. C. uterine enlargement. resulting in the typical “waddling” gait. sperm maturity. the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation. the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Gravity plays only a minor role with these symptoms. Chloasma. and quickening. 2. the woman typically feels awkward. passivity. B. fear. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks. Common emotional reactions during this trimester include narcissism. Constipation. First-trimester classes commonly focus on such issues as early physiologic changes. 12. the father’s body is not capable of providing the milk for the newborn. a finding of a titer less than 1:8 is significant. In addition. providing fewer chances for bonding. sexuality during pregnancy. or he may be jealous of the infant’s demands on his wife’s time and body. During the third trimester. The FHR can be auscultated with a fetoscope at about 20 week’s gestation. fantasies. During the first trimester. The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. the client’s EDD is April 12. or introversion. which may interfere with feeding the newborn. true labor contractions occur at regular intervals. Danger signs that require prompt reporting leaking of amniotic fluid. add 7 days. 18. D. Thurs. or having a spontaneous or missed abortion impending can all produce false-negative results. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. 19. A greater chance for error is associated with bottle feeding. and nasal stuffiness are common discomforts associated with pregnancy. usually starting in the back and sweeping around to the abdomen. With breast feeding. cannot be heard any earlier than 10 weeks’ gestation. The interval of true labor contractions gradually shortens. the fundus is out of the pelvis above the symphysis pubis. thus minimizing blood loss. and unattractive. A. and elevated blood pressure. A rubella titer should be 1:8 or greater. 14. Therefore. 17. and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). C. rapid weight gain. Second and third trimester classes may focus on preparation for birth. A hematocrit of 33. To determine the EDD when the date of the client’s LMP is known use Nagele rule. or anxiety.D. parenting. To the first day of the LMP. vaginal bleeding. When the LMP is unknown. D. clumsy. blurred vision. 20. The second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and development. 11. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. With true labor. contractions increase in intensity with walking.000/mm3. fetal development. At times the woman may seem egocentric and self-centered. At approximately 12 to 14 weeks. common emotional reactions include ambivalence. . A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy. breast tenderness. and nutrition. FHR. D.5% a white blood cell count of 8. indicating that the client may not possess immunity to rubella. and a 1 hour glucose challenge test of 110 g/dl are with normal parameters. A. and newborn care. often becoming more introverted or reflective of her own childhood. 15. subtract 3 months. 16. 13. No preparation is required for breast feeding. Some early classes may include pregnant couples. Breast feeding is advantageous because uterine involution occurs more rapidly. the gestational age of the fetus is estimated by uterine size or position (fundal height). C. storing the urine sample too long at room temperature. B. Regional anesthesia is associated with adverse reactions such as maternal hypotension. 26. . delayed establishment of feeding (e. Neither fontanel should appear bulging. 22. 21. C. The fourth stage of labor lasts from 1 to 4 hours after birth. and ductus venosus are obliterated at birth. which begins with the delivery of the newborn. 27. ductus arteriosus. internal rotation. closes at 8 to 12 weeks. Crowing. Inspecting the umbilical cord aids in detecting cord anomalies. Barbiturates are rapidly transferred across the placental barrier.g. Tranquilizers are associated with neonatal effects such as hypotonia. 24. Neonatal side effects of barbiturates include central nervous system depression. 25. hypothermia. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. A. 29. During the third stage of labor. extension. C. D. If the newborn was awake. Suctioning with a bulb syringe helps maintain a patent airway. The umbilical vein. the cardinal movement of external rotation occurs. Descent flexion. Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper. placing the newborn under a radiant warmer aids in maintaining his or her body temperature. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. 28. B. The newborn’s ability to regulate body temperature is poor. The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. Additionally. which may indicate increased intracranial pressure. which occurs when the newborn’s head or presenting part appears at the vaginal opening. The anterior fontanel is larger in size than the posterior fontanel. Mucus would not produce a stain. During the third stage of labor. the anterior fontanel. the normal heart rate would range from 120 to 160 beats per minute. or partial or total respiratory failure. allergic or toxic reaction. and restitution (in this order) occur before external rotation. 23. Immediately before expulsion or birth of the rest of the body. and lack of an antagonist makes them generally inappropriate during active labor. Therefore. or sunken. whereas the posterior fontanel. occurs during the second stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor. which may indicate dehydration. due to poor sucking reflex or poor sucking pressure). generalized drowsiness. closes at 18 months. prolonged drowsiness. which is triangular shaped. and reluctance to feed for the first few days. cervical dilation and effacement occur. Bilirubin and iron are from hepatic adaptation. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. B. which is diamond shaped. During the first stage of labor. during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.B. B. the newborn and placenta are delivered. D. causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn. Narcotic analgesic readily cross the placental barrier. Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life. 31. possibly reporting sudden intense localized uterine pain. 38. Diarrhea does not occur with hyperemesis. . there may be a dark brown vaginal discharge. A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy. sneeze. Early morning headache is not a classic sign of PIH. Hyperemesis is not a form of anemia. cough. and nutritional imbalances in the absence of other medical problems. 34. and cervical dilation. With the startle reflex. A client with abruptio placentae may exhibit concealed or dark red bleeding. a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. and begins to suck when the cheeks. negative pregnancy test. the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. B. or corner of mouth is touched. which. the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface. A. 33. Uterine anomalies abdominal trauma. Blink. 37. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation. causing painless bleeding in the third trimester of pregnancy. if it continues. Bright red. Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy. 35. 36. C. Reflexes such as rooting and stepping subside within the first year. can deplete the nutrients transported to the fetus. D. 32. A. An incomplete abortion presents with bleeding. laceration of the cervix. usually with severe hemorrhage. B. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions. Edema of the hands and face is a classic sign of PIH. Placenta previa refers to implantation of the placenta in the lower uterine segment. With the rooting and sucking reflex. leading to electrolyte. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis. swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. which could lead to such complications as fetal distress. Many healthy pregnant woman experience foot and ankle edema. B. cramping. and uterine rupture. and the fetal presenting part may be engaged. painless vaginal bleeding. The cervix remains closed.B. lip. abruptio placentae. and cessation of uterine growth and breast tenderness. With the babinski reflex. metabolic. Multiple gestation is one of the predisposing factors that may cause placenta previa. and products of conception are not expelled. B. The description of hyperemesis gravidarum includes severe nausea and vomiting. there is early fetal intrauterine death. With the crawl reflex. A weight gain of 2 lb or more per week indicates a problem. The uterus is typically firm to boardlike. amniotic fluid embolism. In a missed abortion. the newborn turns his head in the direction of stimulus. Weak contractions would not 30. opens the mouth. with no cervical dilation. and renal or vascular disease may predispose a client to abruptio placentae. Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds. 45. and increased restlessness and anxiety are not associated with hyperstimulation. A. Malpresentation and an incompetent cervix may be causes of PROM. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used. The other time periods are inaccurate.occur. But these actions have no effect on minimizing the pressure on the cord. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection. With mastitis. Typically. replacing lost fluids. 44. and wrapping the cord with sterile saline soaked warm gauze are important. not 4 hours. Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility. evaluating fetal responses and preparing for surgery. is the primary predisposing factor. pelvis (passage). Dystocia is difficult. Any amount less than this not considered postpartum hemorrhage. 41. 47. the priority is to prevent and limit hypovolemic shock. and type of anesthetic to be used. Blood components combining to form an . B. A. not mastitis. Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. Epidemic and endemic infections are probable sources of infection for mastitis. Therefore. and cracking of the nipples. Pain. With uterine rupture. The nurse is responsible for reinforcing the explanations about the surgery. D. such as overdistention. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed. B. instituting complete bed rest. stasis. injury to the breast. 40. before labor begins. This is the client’s most immediate need at this time. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth. Monitoring maternal vital signs and FHR. 43. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Fetal viability and gestational age are less immediate considerations that affect the plan of care. D. and medical factors may contribute to the mechanical factors that cause dystocia. Obtaining blood specimens. 46. 42. and elevating the maternal hips on a pillow to minimize the pressure on the cord. Allowing the mother’s support person to remain with her as much as possible is an important concept. C. uterus (powers). and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture. the client is at risk for hypovolemic shock. The immediate priority is to minimize pressure on the cord. although doing so depends on many variables. providing drug therapy as needed. prolonged labor due to mechanical factors involving the fetus (passenger). B. notifying the physician and preparing the client for delivery. the depth and breadth of instruction will depend on circumstances and time available. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. bright red vaginal bleeding. Nutritional. environment. expected outcome. Immediate steps should include giving oxygen. D. PROM occurs about 1 hour. or psyche. painful. one of the most serious is the fetus loss of an effective defense against infection. PROM can precipitate many potential and actual problems. 39. hematuria nocturia. and suprapubic pain. in the femoral vein. dysuria. Oral contraceptives may be started within the first postpartum week to ensure suppression of ovulation. fever. hypertension. An IUD may increase the risk of pelvic inflammatory disease. postpartum infection. especially in women with more than one sexual partner. but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections. 52. Side effects and drug interactions may occur with oral contraceptives regardless of the time the pill is taken. C. In addition. the diaphragm must be refitted. endometrial hyperplasia or carcinoma. 30% to 50%. the presence of Homans sign. and swelling of the affected limb. 48. vomiting. nausea. Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. An UID should not be used if the woman has an active or chronic pelvic infection. Therefore. B. Dehydration. tenderness. The ranges of 10% to 40%. C. Classic symptoms of DVT include muscle pain. 51. Chills. Clots lodging in the pulmonary vasculature refers to pulmonary embolism. C. For the couple who has determined the female’s fertile period. and chills are not typically associated with cystitis. 50. follicles do not mature. Condoms. using the rhythm method. dysuria. frequency. fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. urgency. High fever chills. . along the vein reflect superficial thrombophlebitis. flank pain. and redness. between 50% and 80% of all new mothers report some form of postpartum blues. and pregnancy is prevented. B. Midcalf pain. they do not provide reliable protection against the spread of sexually transmitted infections. C. According to statistical reports. when used correctly and consistently. Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations. However. 54. Although spermicides kill sperm. Manifestations of cystitis include. femoral thrombophlebitis. Male sterilization eliminates spermatozoa from the ejaculate. Because of the changes to the reproductive structures during pregnancy and following delivery. because of the increased risk of sexually transmitted infections. spermicidal jelly should be placed in the dome and around the rim. 49. Chills. especially intracellular organisms such as HIV. are the most effective contraceptive method or barrier against bacterial and viral sexually transmitted infections. The estrogen content of the oral site contraceptive may cause the nausea. A. avoidance of intercourse during this period. is safe and effective. for maximum effectiveness. spermicidal jelly should not be inserted into the vagina until involution is completed at approximately 6 weeks. which could place the client at risk for infection transmission. Use of a female condom protects the reproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. ovulation is inhibited. fever. regardless of when the pill is taken. 53. The diaphragm must be fitted individually to ensure effectiveness. and 25% to 70% are incorrect. usually at the 6 weeks’ examination following childbirth or after a weight loss of 15 lbs or more. and frequency are associated with pvelonephritis.aggregate body describe a thrombus or thrombosis. stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis. A weight gain of ½ pound per week would be 20 pounds for the total pregnancy. a total weight gain 25 to 30 pounds is recommended: 1. During the third trimester. 59.5 pounds in the first 10 weeks. As a result. To calculate the EDD by Nagele’s rule. soft consistency to the stool. To obtain the date of December 27. The client has been pregnant four times. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. Eight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation. including current pregnancy (G). She has two living children (L). IUDs may be inserted immediately after delivery. Use for more than 1 week can also lead to laxative dependency. add 7 days to the first day of the last menstrual period and count back 3 months. 57. 58. 9 pounds by 30 weeks.or uterine abnormalities. To obtain a date of September 27. 7 days were added to the last day of the LMP (rather than the first day of the LMP) and December indicates counting back only 1 month (instead of 3 months) from January. To obtain the date of November 7. The pregnant woman should gain less weight in the first and second trimester than in the third. During the first trimester. 7 days have been added to the last day of the LMP (rather than the first day of the LMP). not midway between the umbilicus and the xiphoid process. Although there is a slightly higher risk for infertility in women who have never been pregnant. D. Liquid in the diet helps provide a semisolid. the uterus rises out of the pelvis and is palpable above the symphysis pubis. Enemas could precipitate preterm labor and/or electrolyte loss and should be avoided. but this is not recommended because of the increased risk and rate of expulsion at this time. At 12 weeks gestation. D. Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity. A spontaneous abortion occurred at 8 weeks (A). The Doppler intensifies the sound of the fetal pulse rate so it is audible. 55. B. the uterus has not risen to the umbilicus at 12 weeks. To ensure adequate fetal growth and development during the 40 weeks of a pregnancy. stool is softer and easier to pass. changing the year appropriately. thus decreasing the amount of water that is absorbed. Although the external electronic fetal monitor would project the FHR. Age is not a factor in determining the risks associated with IUD use.5 pounds by 40 weeks. the enlarging uterus places pressure on the intestines. less than the recommended amount. B. not 1 pound per week. Most IUD users are over the age of 30. plus 4 months (instead of 3 months) were counted back.5 pounds in the first 10 weeks. This coupled with the effect of hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). C. 56. Birth at 38 weeks’ gestation is considered full term (T). The fetal heart rate at this age is not audible with a stethoscope. 7 days have been subtracted (instead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January. the client should only gain 1. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. while birth form 20 weeks to 38 weeks is considered preterm (P). the IUD is an acceptable option as long as the risk-benefit ratio is discussed. Increasing fiber in the diet will help fecal matter pass more quickly through the intestinal tract. and 27. . Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. especially lactating mothers. it is essential that the woman empty her bladder. diet therapy is the mainstay of the treatment plan and should always be the priority. C. Thus. Feeding more frequently. however. because it burns up glucose. Narcotics administered prior to breast feeding are passed through the breast milk to the infant. The three classic signs of preeclampsia are hypertension. and promote ease of correct latching-on for feeding. the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. The client may have a limited knowledge of the pathology and treatment of the condition and will most likely experience grieving. A. All pregnant women with diabetes should have periodic monitoring of serum glucose. Before uterine assessment is performed. will decrease the infant’s frantic. The standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2 weeks. However. 64. . After 20 weeks’ gestation. In a complete abortion all the products of conception are expelled. the nurse would document an imminent abortion. Exercise. 61. 63. Soaps are drying to the skin of the nipples and should not be 60. but there is no cervical dilation. Depression may cause either anorexia or excessive food intake. dietary intake. which may be caused by fluid retention manifested by edema. those with gestational diabetes generally do not need daily glucose monitoring. and proteinuria. edema. Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. However. especially of the hands and face. cramping and vaginal bleeding are present. but is not necessary prior to assessment of the uterus. about every 2 hours. is the priority. is important for all pregnant women and especially for diabetic women. is the primary symptom. 62. D. Thus. should wear a supportive brassiere with wide cotton straps. usually unilateral. B. preeclampsia should be suspected. not exercise. All postpartum clients. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. This does not. Although all of the choices are important in the management of diabetes. causing excessive sleepiness. lower abdominal pain. Nipple soreness is not severe enough to warrant narcotic analgesia. A missed abortion is early fetal intrauterine death without expulsion of the products of conception. soften the breast. the priority consideration at this time. however. Ambulating the client is an essential component of postpartum care. Uterine assessment should not cause acute pain that requires administration of analgesia. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall.A. Although urine is checked for glucose at each clinic visit. when there is a rapid weight gain. Although the potential for infection is always present. pain is the priority. vigorous sucking from hunger and will decrease breast engorgement. In a threatened abortion. leading to excessive weight gain or loss. For the client with an ectopic pregnancy. thus decreasing blood sugar. excessive intake would not be the primary consideration for this client at this time. This is not. B. prevent or reduce nipple soreness. The symptoms may subside or progress to abortion. but this is not the priority at this time. 65. this is not the priority. However. Thus. which can become sore and painful. may be present with breast engorgement. Although rechecking the blood pressure may be a correct choice of action. and bacteria. Then it would be appropriate to check the uterus. Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes. Although promoting comfort and restoration of health. but especially 5 days after delivery. thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua. Temperatures up to 100. Placing the infant under the radiant warmer after bathing will assist the infant to be rewarmed. they are not the priority focus in the limited time presented by early post-partum discharge. frequency. Dry nipple skin predisposes to cracks and fissures. symptoms of urinary tract infections. 66. the nurse’s priority is to facilitate the safe and effective care of the client and newborn. Any bright red vaginal discharge would be considered abnormal. The client data do not include dysuria. 67. D. All the client’s data indicate a uterine problem. which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Thus placing the newborn’s crib close to the viewing window would be least effective. and foul smelling. containing epithelial cells. A weak. The data suggests an infection of the endometrial lining of the uterus. exploring the family’s emotional status. and teaching about family planning are important in postpartum/newborn nursing care. epithelial cells. providing further evidence of a possible infection. transient fever. cervical mucus. 68. when the lochia is typically pink to brownish. and uterine involution would not be affected. Heat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows. Body heat is lost through evaporation during bathing. cholesterol crystals. C. Lochia rubra. 70. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. decidua. not a breast problem. A. Covering the scale with a warmed blanket prior to weighing prevents heat loss . leukocytes. usually 101ºF. C. and microorganisms. which may be a possible cause of the hemorrhage. is present for 2 to 3 days after delivery. it is not the first action that should be implemented in light of the other data. the nurse should check the amount of lochia present. 69. but the nurse should check the extent of vaginal bleeding first. dark brown in appearance. a dark red discharge. The data indicate a potential impending hemorrhage. leukocytes and decidua. The lochia may be decreased or copious. Symptoms of mastitis include influenza-like manifestations.used on the breasts of lactating mothers. cervical mucus. erythrocyes. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery. Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms. or urgency. Typically. fat. erythrocytes. which would necessitate assessing the client’s urine. Because of early postpartum discharge and limited time for teaching. D. B. signs will not appear within 4 hours after the surgical procedure. but it is not a sign of increased intracranial pressure. The primary discomfort of circumcision occurs during the surgical procedure. This reply by the nurse would cause the mother to have undue anxiety. not as a prophylaxis. 75. The infant is not at increased risk for gastrointestinal problems. The data given reflect the normal changes during this time period. the physician does not need to be notified and oxygen is not needed. The postterm meconium-stained infant is not at additional risk for bowel or urinary problems. Breast tissue does not hypertrophy in the fetus or newborns. Suctioning is not necessary. 4 or 6 ounces are incorrect. 72. Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. do the following mathematical calculation. In talipes equinovarus (clubfoot) the foot is turned medially. Hypothyroiddism has no effect on the primitive reflexes. Absence of the Moror reflex is the most significant single indicator of central nervous system status. with the heel elevated. Although the infant has been given vitamin K to facilitate clotting. gagging or coughing. A. The xiphoid and . Hemorrhage is a potential risk following any surgical procedure. D. Although feedings are withheld prior to the circumcision. B. A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction. Thus. A knit cap prevents heat loss from the head a large head. not afterward. flexible. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding. which are signs of excessive secretions. The cord should be kept dry until it falls off and the stump has healed. To determine the amount of formula needed. the prophylactic dose is often not sufficient to prevent bleeding. 71. Although infection is a possibility. 73. 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data do not indicate the presence of choking. 74. Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed. paper measuring tape. The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. 77. The nurse should use a nonelastic. Based on the calculation. Antibiotic ointment should only be used to treat an infection. Newborns do not have breast malignancy.through conduction. 2. 76. causing mechanical obstruction or chemical pneumonitis. which will spontaneously resolve in 4 to 5 days after birth. C. B. The presence of excessive estrogen and progesterone in the maternal-fetal blood followed by prompt withdrawal at birth precipitates breast engorgement. B. Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. and in plantar flexion. it is noninfectious (sterile) and nonirritating. At birth some of the meconium fluid may be aspirated. The infant’s assessment data reflect normal adaptation. Even though the skin is stained with meconium. a large body surface area of the newborn’s body. The feet are not involved with the Moro reflex. the chances of dehydration are minimal. B. 78. placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. and maternal estrogen secretion occurs in every pregnancy. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication. the 6-weeks’ examination has been used as the time frame for resuming sexual activity. Ballottement indicates passive movement of the unengaged fetus. 86. Choice of a contraceptive method is important. reduce blood pressure. Skene’s glands open into the posterior wall of the female urinary meatus. . Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. 85. but it may be resumed earlier. Because of edema. Ballottement is not a contraction. The fetal gonad must secrete estrogen for the embryo to differentiate as a female. Injections into this muscle in a small child might cause damage to the radial nerve. 83. A. 79. C. Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. Culturally. Secretion of androgen by the fetal gonad would produce a male fetus. Seizure precautions provide environmental safety should a seizure occur. the gluteus maximus muscle should not be until the child has been walking 2 years. Using bicarbonate would increase the amount of sodium ingested. Cessation of the lochial discharge signifies healing of the endometrium. 84. The clitoris is female erectile tissue found in the perineal area above the urethra. B. Bartholin’s glands are the glands on either side of the vaginal orifice. Maternal androgen secretion remains the same as before pregnancy and does not effect differentiation. 80. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. daily weight is important but not the priority. D. Braxton Hicks contractions are painless contractions beginning around the 4 th month. 81. Fetal kicking felt by the client represents quickening. Eating low-sodium crackers would be appropriate. C. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control. Chadwick’s sign refers to the purple-blue tinge of the cervix.umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement). Eating six small meals a day would keep the stomach full. Because of the proximity of the sciatic nerve. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion. B. The parotid glands are open into the mouth. but not the specific criteria for safe resumption of sexual activity. Enlargement and softening of the uterus is known as Piskacek’s sign. Goodell’s sign indicates softening of the cervix. which can cause complications. Flexibility of the uterus against the cervix is known as McDonald’s sign. D. The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. and promote diuresis. 82. B. An increase in maternal estrogen secretion does not effect differentiation of the embryo. which often decrease nausea. The client should be placed on her left side to maximize blood flow. The deltoid muscle of a newborn is not large enough for a newborn IM injection. but seizure precautions are the priority. 91. Preparing for cesarean section is unnecessary at this time. Breathing techniques do not eliminate pain. The zygote is the single cell that reproduces itself after conception. 96. B. It is too early to anticipate client pushing with contractions. Administering light sedative would be done for hypertonic uterine contractions. Monitoring the contractions will help evaluate the progress of labor. D. With a vertex presentation. not just most of it. Pica refers to the oral intake of nonfood substances. 97. Breathing techniques can raise the pain threshold and reduce the perception of pain. D. and common chorion. downy hair on the shoulders and back of the fetus. They also promote relaxation. the statement does not explain why the hemorrhage could occur. The greenish tint is due to the presence of meconium. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The chromosome is the material that makes up the cell and is gained from each parent. With this presentation. The nurse should call the physical and obtain an order for an infusion of oxytocin. D. not breathing.C. D. increases uteroplacental perfusion. 95. The client’s labor is hypotonic. Fetal heart rate is important to assess fetal well-being and should be done. 89. D. the placenta is covering all the cervix. Prepared childbirth was the direct result of the 1950’s challenging of the routine use of analgesic and anesthetics during childbirth. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. because of the space between the presenting part and the cervix. but they can reduce it. 92. 93. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. In a breech position. With a face presentation. The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. Quickening is the woman’s first perception of fetal movement. With a complete previa. which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. The LDRP was a much later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. C. A. A. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. 88. C. cheesy substance covering the fetus. The other positions would be incorrect. the head is completely extended. the head would be partially extended. 90. Blastocyst and trophoblast are later terms for the embryo after zygote. A complete placenta previa occurs when the placenta covers the opening of the uterus. Monozygotic (identical) twins involve a common placenta. Positioning. Although a cesarean would help to prevent hemorrhage. 94. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. 87. thus blocking the passageway for the baby. Telling the client to ask the physician is a poor response and would increase the patient’s anxiety. Lanugo is the soft. Roles for nurse midwives and clinical nurse specialists did not develop from this challenge. prolapse of the umbilical cord is common. Assessing maternal vital signs can help determine maternal physiologic status. Hydramnios represents excessive amniotic fluid. same genotype. Vernix is the white. the fetal upper torso and back face the left upper maternal abdominal wall. With a brow (forehead) presentation. . the head is completely or partially flexed. infants need to have their needs met consistently and effectively to develop a sense of trust. Infants need to have their security needs met by being held and cuddled. assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Toddler growth patterns occur in a steplike. Preschoolers develop guilt 98. 101. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. Assuming that the child s hungry may cause overfeeding problems such as obesity. Infants develop mistrust when their needs are not consistently gratified. Therefore.C. not increases. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. The symphysis pubis. toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. B. D. According to Erikson. Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. The anterior fontanelle typically closes anywhere between 12 to 18 months of age. This association does not occur until late infancy or early toddlerhood. 105. 99. . Letting the infant cry for a time before picking up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young age. not linear pattern. this toy is unsafe for children younger than 3 years. Any time earlier would be inappropriate. and pubic arch are not part of the mid-pelvis. During toddlerhood. B. Balloons are contraindicated because small children may aspirate balloons. such as in the case of the infant of a substance-abusing mother. 104. Toddlers develop a sense of shame when their autonomy needs are not met consistently. 103. will develop a sense of uncertainty. food intake decreases. 107. A busy box facilitates the fine motor development that occurs between 4 and 6 months. The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. The menstrual. Testosterone is produced by the Leyding cells in the seminiferous tubules. According to Erikson. secretory and ischemic phases do not contribute to this variation. 106. 100. Follicle-stimulating hormone and leuteinzing hormone are released by the anterior pituitary gland. they are unable to make the connection between crying and attention. A. the earliest age at which to introduce foods is 4 months. B. Infants cry for many reasons. A 5-month-old is too young to use a push-pull toy. D. Schoolagers develop a sense of inferiority when they do not develop a sense of industry. Variations in the length of the menstrual cycle are due to variations in the proliferative phase. D. B. At 2 months of age. B. 102. leading to mistrust of caregivers and the environment. Because it is normal finding for this age. Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. An infant whose needs are consistently unmet or who experiences significant delays in having them met. Thus. notifying he physician or performing additional examinations are inappropriate. The hypothalamus is responsible for releasing gonadotropin-releasing hormone. sacral promontory. Because the button eyes of a teddy bear may detach and be aspirated. logical operations. Multiple-piece toys. a locked door is frightening and potentially hazardous. The child must be able to sate the need to go to the bathroom to initiate toilet training. a child needs to be dry for only 2 hours. 113. schoolagers should be able to . Although they may enjoy looking at some of the pictures. experiencing food jags and eating large amounts one day and very little the next. ordering dolls by size. Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors. The schoolager’s cognitive level is sufficiently developed to enable good understanding of and adherence to rules. and ghosts. 114. Building blocks and wooden puzzles are appropriate for encouraging fine motor development. are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Comic books are on too high a level for toddlers. and squat. A toddler’s appetite and need for calories. expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors. Regression is seen in toddlers and preshcoolers when they retreat or return to an earlier level of development. marked by inductive reasoning. such as puzzle. and simple problem-solving options are examples of the concrete operational thinking of the schoolager. not 4 hours. C. Toddlers typically enjoy socialization and limiting others at meal time. In reaction formation. A new sibling would most likely hinder toilet training. which may affect the child’s going to bed at night. protein. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. Big wheels and tricycles encourage gross motor development. Thus. being left alone especially at bedtime. which are not developed until adolescence.when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met. Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness. 112. 108. finger paints would be an appropriate toy choice. C. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time. The ability to consider the future requires formal thought operations. and reversible concrete thought. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep. Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Toddlers become picky eaters. Collecting baseball cards and marbles. walk. allowing preschoolers to engage in rich fantasy play. 110. The child also must be able to sit. The child should sleep in his own bed. Usually. 109. A. Thus. Dress-up clothes enhance imaginative play and imagination. D. 115. D. toddlers are more likely to rip a comic book apart. D. Reaction formation is the schoolager’s typical defensive response when hospitalized. B. Additionally. Toddlers prefer to feed themselves and thus are too young to have table manners. Preschoolers commonly have fears of the dark. 111. Miniature cars also have a high potential for aspiration. and fluid decrease due to the dramatic slowing of growth rate. The school-aged child is in the stage of concrete operations. C. Telling the child about locking him in his room will viewed by the child as a threat. Collective. The child should participate and play an active role in developing possible solutions. the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. School-age children begin to internalize their own controls and need less outside direction. the child has been exposed to such behavior. which are potentially lethal but tempting. 118. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. especially because of increased motor abilities and independence. Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time her spends on it shuts off further investigation and is likely to make the adolescent and his parents feel defensive. With growth comes greater freedom and children become more adventurous and daring. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. Uterine growth and broadening of the pelvic girdle occurs before menarche. Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. A. B. Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. These hazards. Toddlers develop a sense of shame when they do not achieve autonomy. alcohol. Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings. Immunization for diphtheria and tetanus is required at age 13. The most significant skill learned during the school-age period is reading. 119. C. 116. The school-aged child is also still prone to accidents and home hazards. According to Erikson. Doing so reinforces the child’s feelings of worthlessness and dependency. and sexual abuse should be suspected. 120. may include firearms. If a child does so. although important. Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. . 117. D. Plus the home hazards differ from other age groups. role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics. are not most significant skills learned. ordering. 121. The child should attend school even during resolution of the problem. Discussing the cleansing method shows interest and concern for the adolescent and also can help to identify any patient-teaching needs for the adolescent regarding cleansing. and sorting. Plus the child is away from home more often. The parents need more teaching if they state that they will keep the child home until the phobia subsides. C. and medications. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities. 122. Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. School-age children develop a sense of inferiority when they do not develop a sense of industry. A. A.understand the potential dangers around them. Whether or nor the child knows how to play with dolls is irrelevant. Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions. The statement about peer acceptance and time spent in front of the mirror for the development of self image provides information about the adolescent’s needs to the parents and may help to gain trust with the adolescent. and tetanus vaccine. The Moro reflex typically diminishes or subsides by 3 months. a leading cause of death in children with ALL. There is no association between cleft palate and congenial ear deformities. Iron-rich foods help with anemia. Toddlers engaging in parallel play will play near each other. Acute lymphocytic leukemia (ALL) causes leukopenia. Food particles do not pass through the cleft and into the Eustachian tubes. children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media. the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. The adolescent who becomes pregnant typically denies the pregnancy early on. Because of the structural defect. A. the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion. Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data. Therefore. they are exhibiting parallel play. A. 128. when two toddlers sit near each other but play with separate dolls. iron deficiency anemia. No dietary restrictions are necessary after this injection is given. The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility. C. but not with each other. The parachute reflex appears at 9 months. Although the nurse should notify the physician. Most teenage pregnancies are unplanned and occur out of wedlock. 127. 125. Thus. the mother’s verbalization of information about measures to reduce fever indicates understanding. Therefore. However. and fetopelvic disproportion as well as numerous psychological crises. but dietary iron is not an initial intervention. The incidence of adolescent pregnancy has declined since 1991.123. or sharing dolls with two different nurses are all examples of cooperative play. owing to increased risk from bleeding due to thrombocytopenia. C. 129. . Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care. Rolling from front to back usually is accomplished at about 5 months. Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques. A child’s birth weight usually triples by 12 months and doubles by 4 months. prolonged labor. A subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine. the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm. A 3-month-old infant should be able to lift the head and chest when prone. high neonatal mortality. Multiple bruises and burns on a toddler are signs child abuse. the goal is to initiate measures to protect the child’s safety. Sharing crayons. 130. No specific birth weight parameters are established for 7 or 9 months. resulting in immunosuppression and increasing the risk of infection. 126. Multiple bruises and burns are not normal toddler injuries. 124. B. playing a board game with a nurse. Therefore. later on. D. yet morbidity remains high. Injections should be discouraged. Diarrhea is not associated with this vaccine. The pertusis component may result in fever and the tetanus component may result in injection soreness. pertussis. D. not the diphtheria. A. The prognosis of ALL usually is good. Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. and 15 to 18 months and a booster at 4 to 6 years. the urethra is shorter than in males. One common fear is fear of the body mutilation. and then again at 6 to 18 months. 6. Increased fluid intake enables the bladder to be cleared more frequently. D. The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development. the child commonly experiences more fears than at any other time. large blocks would be the most appropriate toy selection. A. Displacement is the transfer of emotion onto an unrelated object. Repression is the submerging of painful ideas into the unconscious. C. reasoning. 133. being able to sit unsupported and also improving his fine motor skills. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. The situation is a possible life-threatening emergency. During the preschool period. The cast. Mobiles pose a danger to older infants because of possible strangulation. the child has mastered a sense of autonomy and goes on to master a sense of initiative. Throat examination may result in laryngospasm that could be fatal. DtaP is routinely given at 2. The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. B. In females. always a pediatric emergency. B. 136. This decreases the distance for organisms to travel. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. Bleeding tendencies. 134. then at 1 to 4 months. D. Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment. and diarrhea and seizure disorders are not associated with congenital heart disease. probably capable of making hand-to-hand transfers. 135. The preschool child uses simple. In this situation. Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation. 137. Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress. thus helping to prevent urinary tract infections. 4. B. so releasing the traction would be inappropriate. . engages in associative. specific action not continued monitoring is indicated. frequent vomiting. Psychosis is a state of being out of touch with reality. not competitive. is being used in this situation for immobilization. The first dose of hepatitis B vaccine is given at birth to 2 months. Having the child lie down would cause additional distress and may result in respiratory arrest.131. 138. the defense mechanism used when a person attributes his or her own undesirable traits to another. play (interactive and cooperative play with sharing). and is able to tolerate longer periods of delayed gratification. The child is exhibiting classic signs of epiglottitis. such as when the mother would kick a chair or bang the door shut. thereby increasing the chance of the child developing a urinary tract infection. 132. Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia. A. The mother is using projection. During this period. Because the 8-month-old is refining his gross motor skills. Children with congenital heart disease are more prone to respiratory infections. not traction. not complex. especially associated with painful experiences. the child will be unable to from the mouth adequately around nipple. Regurgitation is seen more commonly with GER. Mild mental retardation refers to development disability involving an IQ 50 to 70. marked motor delays. fever and explosive diarrhea indicate enterocolitis. C. rather than lethargy. C. Respiratory status may be compromised if the child is fed improperly or during postoperative period. Irritability. 144. the child is not noted as being retarded. but exhibits slowness in performing tasks. wide spacing and plantar crease between the second and big toes. Locomotion would be a problem for the older infant because of the use of restraints. 143. wheat and wheat-containing products must be avoided. B. excess and lax skin. with monitoring more . a life-threatening situation. because of the intestinal obstruction and inadequate propulsive intestinal movement. For the child with Hirschsprung disease. milk. Generally. such as self-feeding. GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. depressed nasal bridge. prolonged fasting. Respiratory distress is unlikely in a routine upper respiratory infection. large protruding tongue. walking. Side-lying does not facilitate drainage as well as the prone position. No alteration in the oral mucous membranes occurs with this disorder. 147. A. A. and taking. Therefore. C. Rice. Because of the defect.139. risk for aspiration. and gait disabilities would be seen in more severe forms mental retardation. this should be noted before there is any change in the child’s weight. 146. and muscle weakness. Little or no speech. 142. If the child is placed in the supine position. A. Down syndrome is characterized by the following a transverse palmar crease (simian crease). high-arched palate. Therefore. Fluid volume deficit. he or she may aspirate. Therefore. 140. thereby requiring special devices to allow for feeding and sucking gratification. the child’s weight is more likely to be decreased. Thickened feedings are used with GER to stop the vomiting. Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. Steatorrhea occurs in malabsorption disorders such as celiac disease. and altered nutrition are appropriate nursing diagnoses. or exposure to anticholinergic drugs. Because of the fluid loss associated with the severe watery diarrhea. The child is acutely ill and requires intervention. No relationship exists between feedings and characteristics of stools and uterine. 141. the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings. ingestion of gluten. the physician should be notified immediately. hyperextensible and lax joints. Children with celiac disease cannot tolerate or digest gluten. D. because of its gluten content. “Currant jelly” stools are characteristic of intussusception. Projectile vomiting is a key symptom of pyloric stenosis. antidiarrheals are not used to treat Hirschsprung disease. A. small nose. GI functioning is not compromised in the child with a cleft lip. Using an infant seat does not facilitate drainage. and chicken do not contain gluten and need not be avoided. is more likely. 145. separated sagittal suture. B. Episodes of celiac crises are precipitated by infections. If feedings are ineffective. 148. Typically. oblique palpebral fissures. Celiac crisis is typically characterized by severe watery diarrhea. episodic abdominal pain is characteristics of intussusception. Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease. 149. Because intussusception is not believed to have a familial tendency. Current. A. jelly-like stools containing blood and mucus are an indication of intussusception. Hirschsprung disease typically presents with chronic constipation. a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. A sausage-shaped mass may be palpated in the right upper quadrant. 150. Stool inspection. pain pattern. Failure to pass meconium is not associated with celiac disease. C. or abdominal wall defect.frequently than every 30 minutes. and abdominal palpation would reveal possible indicators of intussusception. Acute. obtaining a family history would provide the least amount of information. intussusception. 250-ITEM NOVEMBER 2014 NURSE LICENSURE EXAM (NLE) PRACTICE TEST The test will cover the following topics: Blood Disorders Endocrine Disorders Cardiovascular Disorders . Which of the following outcome criteria would the nurse use? A. The client is complaining of severe pain in his feet and hands. High Fowler's with knees flexed D. Popsicle D. The nurse plans to assess circulation in the lower extremities every 2 hours. Position in high Fowler's with knee gatch raised D. A. Sensation reported when soles of feet are touched D.Capillary refill of < 3 seconds 2.Body temperature of 99°F or less B.Lima beans 5. A newly admitted client has sickle cell crisis.Administering Tylenol as ordered 4. Knee-chest C. Cottage cheese C.Peaches B.Semi-Fowler's with legs extended on the bed 3. Which of the following interventions would be of highest priority for this client? A. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. Encouraging fluid intake of at least 200mL per hour C. The pulse oximetry is 92. The nurse is planning care based on assessment of the client. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. Neurolgical Disorders Pregnacy.Side-lying with knees flexed B. Toes moved in active range of motion C. Labor and Delivery Burns Psychological Disorders Immobility Digestive Disorders Wounds 1. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? A. Give a bolus of IV fluids . A 25-year-old male is admitted in sickle cell crisis.Adjust the room temperature B. A 43-year-old African American male is admitted with sickle cell anemia. What is the best position for this client? A.Taking hourly blood pressures with mechanical cuff B. The nurse is conducting a physical assessment on a client with anemia. Weight gain of 10 pounds in 6 months D. Which of the following clinical manifestations would be most indicative of the anemia? A." B. Which of the following statements by the client indicates a need for further teaching? A." C. raisin pie D. "I will wear support hose when I am up. Traveling by airplane for business trips D. Respirations 28 shallow C. Which of the following meal plans would the nurse expect the client to select? A. ice cream C. corn. what body part would be the best indicator? A. The nurse is instructing a client with iron-deficiency anemia.Administer meperidine (Demerol) 75mg IV push 6. Which of the following activities would the nurse recommend? A. Egg salad on wheat bread.A bus trip to the Museum of Natural History 8."I will drink 500mL of fluid or less each day. Examine the feet for petechiae D. C.The client collects stamps as a hobby.Pink complexion 11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia.Shins 10. Because jaundice is often a clinical manifestation of this type of anemia.Pork chop. coleslaw. Chaperoning the local boys club on a snow-skiing trip C. Which of the following would the nurse include in the physical assessment? A. A 33-year-old male is being evaluated for possible acute leukemia. and peach pie B.Conjunctiva of the eye B. Chicken salad sandwich. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. D. An African American female comes to the outpatient clinic. The client recently lost his job as a postal worker. Take the blood pressure C."I will eat foods low in iron. "I will use an electric razor for shaving." 12. and coconut cake 7. French fries. gelatin salad. B. Roof of the mouth D. carrot sticks.Palpate the spleen B.Examine the tongue 9. . lettuce salad.BP 146/88 B.The client's brother had leukemia as a child. The physician suspects vitamin B12 deficiency anemia." D. Which of the following would the nurse inquire about as a part of the assessment? A.C. creamed potatoes.A family vacation in the Rocky Mountains B. The client had radiation for treatment of Hodgkin's disease as a teenager. green beans. Soles of the feet C. Start O2 D.Roast beef. An African American client is admitted with acute leukemia. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). "Have you lost weight recently?" D.Bleeding precautions B.13. the nurse would monitor: A. To determine the client's response to treatment.Partial prothrombin time (PTT) 18. The nurse is assessing for signs and symptoms of bleeding.Platelet count B. The priority intervention for this client is: .The soles of the feet 14. The client's platelet count currently is 80. Anticipatory grieving related to terminal illness C. Fatigue related to the disease process D. Potassium levels D. altered related to chemotherapy B. Which of the following interventions would be appropriate for this client? A. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. The earlobes D.Encourage the Valsalva maneuver for bowel movements 20. Which of the following would be most important for the nurse to inquire? A."Have you noticed a change in sleeping habits recently?" B. polydipsia. A client has autoimmune thrombocytopenic purpura. White blood cell count C.Fatigue related to chemotherapy 17. Which of the following diagnoses would be a priority for this client? A. Tissue integrity related to prolonged bed rest D. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? A.Sexual dysfunction related to radiation therapy B.Place the client in Trendelenburg position for postural drainage B. Elevate the head of the bed 30° D. A client with acute leukemia is admitted to the oncology unit."Have you noticed changes in your alertness?" 15. and mental confusion. The client with a history of diabetes insipidus is admitted with polyuria. Oxygen therapy D. The thorax C. Prevention of falls C. "Have you had a respiratory infection in the last 6 months?" C. Risk for injury related to thrombocytopenia C.Conservation of energy 19.The abdomen B. He is engaged to be married and is to begin a new job upon graduation.Interrupted family processes related to life-threatening illness of a family member 16. Where is the best site for examining for the presence of petechiae? A. It will be most important to teach the client and family about: A. A client with a pituitary tumor has had a transphenoidal hyposphectomy.Oral mucous membrane. Encourage coughing and deep breathing every 2 hours C. Her pulse is 52. Disturbed thought processes r/t interstitial edema D.Impaired physical mobility related to decreased endurance B. C. 27. A client has had a unilateral adrenalectomy to remove a tumor. During administration. A client had a total thyroidectomy yesterday. and the client is wearing two sweaters.Apply ice packs to the forehead and back of the neck 22. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. Check the vital signs C. Sodium and potassium levels monitored D. Which of the following interventions would the nurse implement? A. The client is admitted to the hospital with hypertensive crises. Output D. A 32-year-old mother of three is brought to the clinic.Report muscle weakness to the physician. Intake/output measurements C.Ask the doctor to perform a complete blood count before starting the medication. Hypothermia r/t decreased metabolic rate C. The client is diagnosed with hypothyroidism. Which instruction should be given to the client? A. Diazoxide (Hyperstat) is ordered. there is a weight gain of 30 pounds in 4 months. Allow six months for the drug to take effect. The client is receiving IV glucocorticoids (Solu-Medrol).Measure the urinary output B.Decreased cardiac output r/t bradycardia 26. The client is complaining of tingling around the mouth and in the fingers and toes.Glucometer readings as ordered B. Pinch the soft lower part of the nose for a minimum of 5 minutes D. Which of the following nursing diagnoses is of highest priority? A. the nurse should: A. To prevent complications. the most important measurement in the immediate post-operative period for the nurse to take is: A. B. Which nursing action is most appropriate to control the bleeding? A.Obtain a crash cart B. D. Assess the dressing for drainage D. Check the calcium level C. Pack the nares tightly with gauze to apply pressure to the source of bleeding C.Weigh the client 21. A client with hemophilia has a nosebleed. Encourage increased fluid intake D.Assess the blood pressure for hypertension 25.Specific gravity 23. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Temperature C.Blood pressure B. What would the nurses' next action be? A. Take the medication with fruit juice.Place the client in a sitting position with the head hyperextended B.A.Utilize an infusion pump .Daily weights 24. The nurse is checking the client's central venous pressure. Measuring the intake and output D. Administer the medications C.Macaroni and cheese B.Contact the pharmacy 34.Cover the solution with foil 28.Weighing the client daily B. Measuring the extremity C. Administer separately D.Replenish his supply every 3 months B. The client should be instructed to: A. Blood glucose of 110mg/dL C. Hands D. Check the blood glucose level C. The best method of evaluating the amount of peripheral edema is: A. Neck C.Phlebostatic axis B. Place the client in Trendelenburg position D.Sacrum 32. Erb's point D.B.Crush the medication and take with water 30. The nurse should: A. The nurse should place the zero of the manometer at the: A. Turkey breast D. In assessing the client for edema. A client with vaginal cancer is being treated with a radioactive vaginal implant. Shrimp with rice C. Which diet selection is lowest in saturated fats? A. The client is instructed regarding foods that are low in fat and cholesterol. The client's husband asks the nurse if he can spend the night with his wife. Which finding should be reported to the doctor? A. the nurse should check the: A.Blood pressure of 126/80 B.Respiratory rate of 30 per minute 29.Tail of Spence 33. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. PMI C. The client admitted with angina is given a prescription for nitroglycerine. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The client is admitted with left-sided congestive heart failure.Feet B.Spaghetti 31. Take one every 15 minutes if pain occurs C. Heart rate of 60bpm D.Question the order B.Checking for pitting 35. The nurse should explain that: . Leave the medication in the brown bottle D. iced tea B. The physician has prescribed Novalog insulin for a client with diabetes mellitus.Call security for assistance and prepare to sedate the client."I will make sure I eat breakfast within 10 minutes of taking my insulin. There is no need for him to stay because staffing is adequate.30 minutes after meals 42. Increase the number of circulating neutrophils D.Leave the client alone until he calms down.MMR 41. pudding. iced tea 37. D. In a single dose at bedtime D. The umbilical cord needs time to separate. The nurse is caring for a client hospitalized with a facial stroke.Visitation is limited to 30 minutes when the implant is in place. D. potato chips. A client with leukemia is receiving Trimetrexate. B. The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to: A. ." B. Which diet selection would be suited to the client? A. His wife will rest much better knowing that he is at home. The nurse should administer the medication: A. Newborn skin is easily traumatized by washing. Tomato soup.Overnight stays by family members is against hospital policy. B. Hepatitis B vaccine D. What is the most appropriate action for the nurse to take? A. "I will need to carry candy or some form of sugar with me all the time.Hamburger. baked beans.Treat iron-deficiency anemia caused by chemotherapeutic agents B. fruit cup. A 4-month-old is brought to the well-baby clinic for immunization. The nurse is teaching basic infant care to a group of first-time parents.A. B.30 minutes before meals B. mashed potatoes. coffee D. Tell the client to calm down and ask him if he would like to play cards. the physician orders Wellcovorin (leucovorin calcium). "I will eat a snack around three o'clock each afternoon.The chance of chilling the baby outweighs the benefits of bathing.Roast beef sandwich. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff." D. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because: A. C. C. In addition to the DPT and polio vaccines. Jello. C.Reverse drug toxicity and prevent tissue damage 40. Split pea soup." C. milk C. 36."I can save my dessert from supper for a bedtime snack. Mumps vaccine C. pickle spear.New parents need time to learn how to hold the baby. D. cheese toast. the baby should receive: A. Tell the client that if he continues his behavior he will be punished. Create a synergistic effect that shortens treatment time C. Which statement indicates that the client knows when the peak action of the insulin occurs? A. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. 39. With each meal C.Hib titer B." 38. After reviewing the client's chart. Cluster headaches 46.Pain on flexion of the hip and knee B. Prinzmetal's angina C. fatigue. The next action the nurse should take is to: A.Check the client for bladder distention B. When the nurse checks the fundus of a client on the first postpartum day. The client with confusion says to the nurse. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Reaction to antiviral medication C. Pain when the head is turned to the left side D. Which of the following in the client's history should be reported to the doctor? A. The client with suspected meningitis is admitted to the unit. Anomia D." B. A positive Kernig's sign is charted if the nurse notes: A. she notes that the fundus is firm. "I haven't had anything to eat all day long. The nurse is aware that the client is experiencing what is known as: A.Check for the expulsion of small clots 44. Tuberculosis D. Which response would be best for the nurse to make? A. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Apraxia C. Sundowning D. The client with dementia is experiencing confusion late in the afternoon and before bedtime. Assess the blood pressure for hypotension C. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The client is seen in the clinic for treatment of migraine headaches.Diabetes B. Determine whether an oxytocic drug was given D. The client's symptoms are consistent with a diagnosis of: A."You know you had breakfast 30 minutes ago.43.Aphasia 48.Superinfection due to low CD4 count 45.Dizziness when changing positions 47.Delusions 49. Cancer D.Pneumonia B. I'll report it to the charge nurse. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. is at the level of the umbilicus. Nuchal rigidity on flexion of the neck C.Agnosia B." . A client is admitted to the hospital with a temperature of 99. The nurse is aware that the client is exhibiting: A.8°F. "I am so sorry that they didn't get you breakfast. complaints of bloodtinged hemoptysis. and night sweats.Chronic fatigue syndrome B. and is displaced to the right. Normal aging C. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which method is used to elicit the biceps reflex? A.Nausea 51.Ovarian cancer 53. the client reports that she has a lesion on the perineum." 50. Confusion D. A client is admitted to the labor and delivery unit in active labor. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. Herpes C. Which laboratory finding is associated with HELLP syndrome? A. Which initial action is most appropriate? A.Elevated blood glucose B. B. . the nurse notes a papular lesion on the perineum. Elevated creatinine clearance D.Syphilis B. A client with a diagnosis of HPV is at risk for which of the following? A. C. Rapid plasma reagin (RPR) C.Condylomata 54. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Further investigation reveals a small blister on the vulva that is painful to touch. Florescent treponemal antibody (FTA) D."You will have to wait a while. Which side effect is most often associated with this drug? A. Headaches C.Urinary incontinence B. Multiple myeloma D.The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.Continue primary care as prescribed 52.Document the finding B. Prepare the client for a C-section D. Would you like something else?" D. Gonorrhea D.Hodgkin's lymphoma B. "I'll get you some juice and toast. Elevated platelet count C.C. lunch will be here in a little while.Elevated hepatic enzymes 56. The nurse is assessing the deep tendon reflexes of a client with preeclampsia.Venereal Disease Research Lab (VDRL) B. During the initial interview.Thayer-Martin culture (TMC) 55. Report the finding to the doctor C. During examination. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow. The best diagnostic test for treponema pallidum is: A. Cervical cancer C. A client visiting a family planning clinic is suspected of having an STI. The nurse is aware that the most likely source of the lesion is: A. The infant is at high risk for respiratory distress syndrome. The nurse should be most concerned about which nursing diagnosis? A. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. Which doctor's order should the nurse question? A. If the client experiences hypotension.The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist. Wakefulness C. Alteration in skin integrity D.Decreased urinary output B. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation.D. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. Which is the best method to use for determining early ascites? A. A client has cancer of the pancreas. 59.Ineffective individual coping 63. Bimanual palpation for hepatomegaly C. the nurse would: A. Alteration in bowel elimination C.Crying B. Stadol 1mg IV push every 4 hours as needed prn for pain D. Absence of knee jerk reflex D. Daily measurement of abdominal girth D.Decreased respiratory rate 61.Yawning 60. C. The nurse is caring for a client with ascites.Assessment for a fluid wave .The infant is at high risk for birth trauma.Ancef 2gm IVPB every 6 hours 58. The infant is at high risk for intrauterine growth retardation. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. An expected side effect of magnesium sulfate is: A.Increase the rate of the IV infusion 62. The nurse's assessment of this data is: A. Administer oxygen per nasal cannula D.Place her in Trendelenburg position B.Inspection of the abdomen for enlargement B. Which observation in the newborn of a diabetic mother would require immediate nursing intervention? A. B. The client has elected to have epidural anesthesia to relieve labor pain. D. Decrease the rate of IV infusion C.The infant is at low risk for congenital anomalies.Alteration in nutrition B. 57.Magnesium sulfate 4gm (25%) IV B. Jitteriness D. Brethine 10mcg IV C. Hypersomnolence C. A cup of yogurt D. Nursing assessment findings include BP 80/34. Which selection would provide the most calcium for the client who is 4 months pregnant? A. and respirations 20. Anticipate an increase in the Coumadin dosage C.Assess for signs of abnormal bleeding B. A bran muffin C. Drinks several carbonated drinks per day C. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. A client being treated with sodium warfarin has a Protime of 120 seconds.Alteration in sensory perception 65. Offer to wash the fruit for the client D. Which is the client's most appropriate priority nursing diagnosis? A. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale.64. Administer atropine intravenously D.Alteration in cerebral tissue perfusion B. Has two sisters with sickle cell tract D.Is taking acetaminophen to control pain 66.Move the emergency cart to the bedside 68. Place the fruit next to the bed for easy access by the client C. Increase the infusion of Dextrose in normal saline C.A granola bar B. Which information obtained on the visit would cause the most concern? The client: A.Order a chest x-ray B. pulse rate 120.A glass of fruit juice . The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which action by the nurse indicates understanding of the management of chest tubes? A. Reinsert the tube C. Instruct the client regarding the drug therapy D.Place the client in Trendelenburg position B.Likes to play football B.Call the doctor 69. a visitor brings a basket of fruit. Ineffective airway clearance D. What action should the nurse take? A.Increase the frequency of neurological assessments 70. with a BP of 90/40 systolic. The client arrives in the emergency department after a motor vehicle accident. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation. Fluid volume deficit C. Which intervention would be most important to include in the nursing care plan? A.Allow the client to keep the fruit B. The initial nurse's action should be to: A.Tell the family members to take the fruit home 67. Cover the insertion site with a Vaseline gauze D. 71."I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing. Hypernatremia D. During the procedure. The nurse would be most concerned with the client developing which of the following? A. "That feeling of warmth is normal when the dye is injected. The nurse places a padded tongue blade at the bedside." D. The nurse is evaluating nutritional outcomes for an elderly client with bulimia. B. "I'm feeing really hot. The client is admitted following repair of a fractured tibia and cast application. The nurse inserts a Foley catheter. Explain the consequences without treatment D.Hyperkalemia 74. Encourage the mother to reconsider C. B. Which action by the healthcare worker indicates a need for further teaching? A.Ask the mother to leave while the blood transfusion is in progress B. D. The nurse is observing several healthcare workers providing care. Laryngeal edema C. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate? A. Which nursing assessment should be reported to the doctor? A. the client tells the nurse. The physician has written an order to transfuse 2 units of whole blood.The client selects a balanced diet from the menu. 75.Paresthesia of the toes 76." B. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL." 77.The nurse darkens the room. When discussing the treatment. C." Which response would be best? A.Hypovolemia B. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate."You are having an allergic reaction. 72. the child's mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. Which data best indicates that the plan of care is effective? A. Pedal pulses weak and rapid D.Notify the physician of the mother's refusal 73. The client's hemoglobin and hematocrit improve. I will get an order for Benadryl." C. The doctor washes his hands before examining the client.The nursing assistant wears gloves while giving the client a bath. The client is having an arteriogram.The nurse places a sign over the bed not to check blood pressure in the right arm. C.The client gains weight. . "That feeling of warmth indicates that the clots in the coronary vessels are dissolving. C. What nursing action is most appropriate? A.The nurse wears gloves to take the client's vital signs. D. The client's tissue turgor improves. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse wears goggles while drawing blood from the client. D. Warm toes C. B.Pain beneath the cast B. 79. Obtaining a sputum specimen D. B. Contacting the physician C. As a result of her actions.Inserting a Foley catheter B.Starting a blood transfusion 85.Treatment is not recommended for children less than 10 years of age. B. 81. Which instruction should be given regarding the medication? A.The client loses consciousness. Which client should be assigned to a private room if only one is available? A. The 5-year-old is being tested for enterobiasis (pinworms). Discontinuing a nasogastric tube C.78. The registered nurse is making assignments for the day. Assault D. The client returns to the unit from surgery with a blood pressure of 90/50. The client is having electroconvulsive therapy for treatment of severe depression. Which client should be assigned to the pregnant nurse? A.Continuing to monitor the vital signs B. Asking the client how he feels . C. Which assignment should not be performed by the licensed practical nurse? A. pulse 132.The client receiving linear accelerator radiation therapy for lung cancer B. The nurse is planning room assignments for the day. The nurse caring for a client in the neonatal intensive care unit administers adultstrength Digitalis to the 3-pound infant. D. D. the nurse should teach the mother to: A.Malpractice 84. Which of the following indicates that the client's ECT has been effective? A.Bring a hair sample to the clinic for evaluation 80. The client with acromegaly D. The entire family should be treated. The client with diabetes C. The client with a radium implant for cervical cancer C. Obtain a stool specimen in the afternoon D. The client's ECG indicates tachycardia.Intravenous antibiotic therapy will be ordered. Scrape the skin with a piece of cardboard and bring it to the clinic C. The client who has just been administered soluble brachytherapy for thyroid cancer D.Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep B. The nurse is teaching the mother regarding treatment for enterobiasis.Negligence B.The client who returned from placement of iridium seeds for prostate cancer 82. The client vomits. Medication therapy will continue for 1 year. and respirations 30. the baby suffers permanent heart and brain damage. The nurse can be charged with: A. Tort C.The client with Cushing's disease B.The client with myxedema 83.The client has a grand mal seizure. Which action by the nurse should receive priority? A. C. To collect a specimen for assessment of pinworms. D.Asking the LPN to continue the post-op care 86. Which nurse should be assigned to care for the postpartal client with preeclampsia? A.The RN with 2 weeks of experience in postpartum B. The RN with 3 years of experience in labor and delivery C. The RN with 10 years of experience in surgery D.The RN with 1 year of experience in the neonatal intensive care unit 87. Which information should be reported to the state Board of Nursing? A.The facility fails to provide literature in both Spanish and English. B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay. D.The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath. 88. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should: A.Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D.Charge the nurse with a tort 89. The home health nurse is planning for the day's visits. Which client should be seen first? A.The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line D.The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter 90. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster? A.A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury D.The client who arrives with a large puncture wound to the abdomen and the client with chest pain 91. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following? A.The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. B. The child should be allowed to instill his own eyedrops. C. The mother should be allowed to instill the eyedrops. D.If the eye is clear from any redness or edema, the eyedrops should be held. 92. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction? A."It is okay to give my child white grape juice for breakfast." B. "My child can have a grilled cheese sandwich for lunch." C. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." D."For a snack, my child can have ice cream." 93. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect? A.Ask the parent/guardian to leave the room when assessments are being performed. B. Ask the parent/guardian to take the child's favorite blanket home because anything from the outside should not be brought into the hospital. C. Ask the parent/guardian to room-in with the child. D.If the child is screaming, tell him this is inappropriate behavior. 94. Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid? A.Remove the mold and clean every week. B. Store the hearing aid in a warm place. C. Clean the lint from the hearing aid with a toothpick. D.Change the batteries weekly. 95. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: A.Body image disturbance B. Impaired verbal communication C. Risk for aspiration D.Pain 96. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? A.High fever B. Nonproductive cough C. Rhinitis D.Vomiting and diarrhea 97. The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available? A.Intravenous access supplies B. A tracheostomy set C. Intravenous fluid administration pump D.Supplemental oxygen 98. A 25-year-old client with Grave's disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal? A.Bradycardia B. Decreased appetite C. Exophthalmos D.Weight gain 99. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions? A.Ham sandwich on whole-wheat toast B. Spaghetti and meatballs C. Hamburger with ketchup D.Cheese omelet 100. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first? A.Notify the physician B. Recheck the O2 saturation level in 15 minutes C. Apply oxygen by mask D.Assess the child's pulse 101. A gravida III para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy? A.Fetal heart tones 160bpm B. A moderate amount of straw-colored fluid C. A small amount of greenish fluid D.A small segment of the umbilical cord 102. The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make? A."We have a name picked out for the baby." B. "I need to push when I have a contraction." C. "I can't concentrate if anyone is touching me." D."When can I get my epidural?" 103. The client is having fetal heart rates of 90–110bpm during the contractions. The first action the nurse should take is: A.Reposition the monitor B. Turn the client to her left side C. Ask the client to ambulate D.Prepare the client for delivery 104. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect: A.A painless delivery B. Cervical effacement C. Infrequent contractions D.Progressive cervical dilation 105. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time? A.Anticipate the need for a Caesarean section B. Apply the fetal heart monitor C. Place the client in Genu Pectoral position D.Perform an ultrasound exam Start an IV C.The bladder fills more rapidly because of the medication used for the epidural. D. D. Lutenizing hormone is high. The nurse is aware that the success of the rhythm method depends on the: A. C.106.The cervix is closed.Potential fluid volume deficit related to decreased fluid intake 108. 112. B. the nurse notes late decelerations on the fetal monitor. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. C. What is the most likely explanation of this pattern? A. B. Alteration in placental perfusion related to maternal position C. Reposition the client D. B. Which one would be most appropriate for the primagravida as she completes the early phase of labor? A. There is a vagal response. The nurse decides to apply an external fetal monitor. 107.Acceleration of FHR with fetal movements 111. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. Impaired physical mobility related to fetal-monitoring equipment D. The nurse notes variable decelerations on the fetal monitor strip. D.Age of the client . The rationale for this implementation is: A. with intact membranes and a fetal heart tone rate of 160–170bpm. C.The contractions are intense enough for insertion of an internal monitor.Readjust the monitor 110. The membranes are still intact. Ominous periodic changes D. A baseline variability of 25–35bpm C. D. B. The endometrial lining is thin. The umbilical cord is compressed.The baby is asleep.Impaired gas exchange related to hyperventilation B. As the client reaches 8cm dilation. The most appropriate initial action would be to: A. A vaginal exam reveals that the cervix is 4cm dilated.A fetal heart rate of 170–180bpm B. C. Her level of consciousness is such that she is in a trancelike state.There is uteroplacental insufficiency. Which of the following is a characteristic of a reassuring fetal heart rate pattern? A.The progesterone level is low.Notify her doctor B.She is embarrassed to ask for the bedpan that frequently. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is: A. 109. A client tells the nurse that she plans to use the rhythm method of birth control. The sensation of the bladder filling is diminished or lost.Estrogen levels are low. 113. The FHR baseline is 165–175bpm with variability of 0–2bpm. The fetal heart tones are within normal limits. The nurse explains that conception is most likely to occur when: A. The presence of fetal heart tones C.B.Elevated human chorionic gonadatropin B. Metabolic acidosis with dehydration C. Which menu selection will best meet the nutritional needs of the pregnant client? A. green beans. If the client misses one or more pills. The doctor suspects that the client has an ectopic pregnancy. gelatin with fruit.Changes in the menstrual flow should be reported to the physician. Hyperglycemic.Metabolic alkalosis with dehydration 118. potato salad. Respiratory acidosis without dehydration D. The nurse is caring for a neonate whose mother is diabetic. The nurse is teaching a pregnant client about nutritional needs during pregnancy. C. and iced tea D. The client with hyperemesis gravidarum is at risk for developing: A. Throbbing pain in the upper quadrant D. Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives? A. The most definitive sign of pregnancy is: A.Hamburger pattie. fruit cup. two pills should be taken per day for 1 week. large for gestational age D. Which symptom is consistent with a diagnosis of ectopic pregnancy? A. Oral contraceptives C.Breast enlargement and tenderness 119. 121. potato chips. French fries. Breastfeeding is contraindicated in the postpartum client with: A.Fish sandwich. small for gestational age 120. An alternate method of birth control is needed when taking antibiotics. The nurse will expect the neonate to be: A. and cola C. Frequency of intercourse C. Diaphragm D. B. and iced tea B.Contraceptive sponge 115. A client tells the doctor that she is about 20 weeks pregnant. Baked chicken. The nurse is discussing breastfeeding with a postpartum client.Hypoglycemic. and coffee 117.Respiratory alkalosis without dehydration B.Intrauterine device B. coleslaw. Which method of birth control is most suitable for the client with diabetes? A.Range of the client's temperature 114.Weight gain should be reported to the physician. Hypoglycemic. small for gestational age B.Painless vaginal bleeding B. Regularity of the menses D.Sudden. Abdominal cramping C. D.Hyperglycemic.Diabetes . large for gestational age C. Roast beef sandwich. baked beans. stabbing pain in the lower quadrant 116. A client with diabetes asks the nurse for advice regarding methods of birth control. Uterine enlargement D. yogurt. Nursing care of the newborn should include: A. Check for cervical dilation C. She experiences abdominal pain and frequent urination. Within 1 week of delivery C. Latent C. A client is admitted to the labor and delivery unit. Which characteristic is associated with babies born to mothers who smoked during pregnancy? A. D. Client's vital signs D. The nurse should tell the client that labor has probably begun when: A.Active B. C.Client's level of discomfort 127.Her contractions are 2 minutes apart. Based on the nurse's assessment the client is in which phase of labor? A. Wrapping the newborn snugly in a blanket C.Obtain a detailed history 123. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. B. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development.Within 1 month of delivery 126. A newborn with narcotic abstinence syndrome is admitted to the nursery.Low birth weight B. Check for firmness of the uterus D. She has back pain and a bloody discharge.Assess the fetal heart tones B. RhoGam should be administered: A. Placing the newborn in the infant seat . Large for gestational age C. Within 2 weeks of delivery D. Positive HIV C. Hypertension D. 124. The nurse's first action should be to: A.Degree of cervical dilation B. Transition D.Within 72 hours of delivery B.Her contractions are 5 minutes apart. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. the nurse's first action should be to assess the: A.B. To provide postpartum prophylaxis. Fetal heart tones C.Thyroid disease 122. After the physician performs an amniotomy.Growth retardation in weight and length 125. Preterm birth. A client telephones the emergency room stating that she thinks that she is in labor.Early 128. but appropriate size for gestation D.Teaching the mother to provide tactile stimulation B. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. The legs are suspended in the traction. Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse's teaching? A. Which symptom is the client with a fractured hip most likely to exhibit? A. The client is admitted for an open reduction internal fixation of a fractured hip. Wash her hands for 2 minutes before care C. Nutritional status D. the nurse should give priority to: A. the nurse should give priority to assessing the: A. Hormonal disturbances C.Genetic predisposition 133.Is used primarily to heal the fractured hips 135. The buttocks are 15° off the bed. Utilizes Kirschner wires D."I must flush the tube with water after feedings and clamp the tube. Following the initiation of epidural anesthesia. A client elects to have epidural anesthesia to relieve the discomfort of labor.Checking for cervical dilation B.Absence of pedal pulses 132. 134.Ask the client to cover her mouth when she coughs 131. B.Obtaining a fetal heart rate 130." . Checking the client's blood pressure D.Lack of exercise B.Utilizes a Steinman pin B. Client's pain C.The infant no longer complains of pain. The nurse knows that a 60-year-old female client's susceptibility to osteoporosis is most likely related to: A.Pain B. Lack of calcium D. Wear a mask when providing care D. Which finding by the nurse indicates that the traction is working properly? A. Placing the client in a supine position C." B. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction: A. C. "I must check placement four times per day. The nurse is aware that the best way to prevent post.Serum collection (Davol) drain B. A client with a fractured hip has been placed in Buck's traction. Requires that both legs be secured C.operative wound infection in the surgical client is to: A. A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction.D. Disalignment C.Initiating an early infant-stimulation program 129.The pins are secured within the pulley.Administer a prescribed antibiotic B. The elderly client is admitted to the emergency room. D. Cool extremity D.Immobilizer 136. Immediately following surgery. The client's hematocrit is 26%. D. 10-year-old male with sarcoma D. B. C. Report chest pain." D. An elderly client with an abdominal surgery is admitted to the unit following surgery. 139.High-seat commode B. Have narcan (naloxane) available C. Remain upright after taking for 30 minutes.16-year-old female with scoliosis B. 143.Allows 24 hours before bearing weight . Which instruction should be included in the discharge teaching? A.Prepare to do cardioresuscitation 141.Allow 6 weeks for optimal effects."If my father is unable to swallow. The client has a temperature of 6°F. Petals the cast C. The nurse is assessing the client with a total knee replacement 2 hours postoperative. Prepare to administer blood products D.The urinary output has been 60 during the last 2 hours. A client with osteoarthritis has a prescription for Celebrex (celecoxib). A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. The client lives in a house built in 1 D. "I will report to the doctor any signs of indigestion. The client's parents are skilled stained-glass artists. Which information in the health history is most likely related to the development of plumbism? A.Bleeding on the dressing is 3cm in diameter.C.Abduction pillow 140." 137. Which information requires notification of the doctor? A. In anticipation of complications of anesthesia and narcotic administration.6-year-old male with osteomylitis 142.Administer oxygen via nasal cannula B. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse: A.The client has several brothers and sisters. 12-year-old male with a fractured femur C. A client with a total hip replacement requires special equipment. D.Take the medication with milk.The client has traveled out of the country in the last 6 months. Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction? A. The nurse is caring for the client with a 5-year-old diagnosis of plumbism. 138. the nurse should: A. Recliner C. TENS unit D. I will discontinue the feeding and call the clinic. B.Handles the cast with the fingertips B. C. Which equipment would assist the client with a total hip replacement with activities of daily living? A. C. Dries the cast with a hair dryer D. B. " C. Which response would be best? A.Asking the LPN to clean the weights and pulleys with peroxide 146. The client with a cervical fracture is placed in traction." C.Client carries the walker 150.144.Crutchfield tong traction 148.Palms rest lightly on the handles B.Cover the cord with a dry. The nurse is aware that the correct use of the walker is achieved if the: A."Use of the CPM machine will alleviate the need for physical therapy after the client is discharged. During pin care." 145." D." B. Elbows are flexed 0° C.Assisting the LPN with opening sterile packages and peroxide B." D. Elevate the client's hips D." B. it is okay. When assessing a laboring client.Check for swelling 147. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. "Because the cast is made of plaster.Russell's traction B. Which action should the nurse take at this time? A. Place the client on her left side C. The nurse should: A." 149. "If the client complains of pain during the therapy. Assess the blood pressure C. "If they don't use chalk to autograph. Which type of traction will be utilized at the time of discharge? A. sterile gauze . Telling the LPN that the registered nurse should perform pin care D. Which action specific to the spica cast should be taken? A. Offer pain medication D. A client with a fractured hip is being taught correct use of the walker."It will be alright for your friends to autograph the cast. she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Buck's traction C.Check the bowel sounds B."Autographing or writing on the cast in any form will harm the cast. A child with scoliosis has a spica cast applied. "The CPM machine controls should be positioned distal to the site. A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period.Attempt to replace the cord B."Use of the CPM will permit the client to ambulate during the therapy. Client walks to the front of the walker D. The nurse is assigned to care for the client with a Steinmen pin. Which statement made by the nurse indicates understanding of the CPM machine? A. the nurse finds a prolapsed cord. Telling the LPN that clean gloves are allowed C. I will turn off the machine and call the doctor. Halo traction D. autographing can weaken the cast. Which statement is true regarding insulin needs during pregnancy? A. While in the emergency room.Duration is measured by timing from the peak of one contraction to the end of the same contraction.151. When caring for the obstetric client receiving intravenous Pitocin. D. The presence of green-tinged amniotic fluid D. Frequent urination C. The nurse is caring for a 30-year-old male admitted with a stab wound. D. Size of the mother's breast D.Moderate uterine contractions 154.The presence of scant bloody discharge B. Fetal bradycardia C.Maternal hypoglycemia B. C. B. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. Which finding should be reported to the physician immediately? A. a chest tube is inserted. D. The nurse should give priority to: A. A client with diabetes visits the prenatal clinic at 28 weeks gestation.Chest tubes assist with cardiac function by stabilizing lung expansion. Obtaining a diet history . A decreased need for insulin occurs during the second trimester. the nurse should monitor for: A.Fetal movement 156.The tube will allow for equalization of the lung expansion. Chest tubes relieve pain associated with a collapsed lung. Infant's birth weight C. B. C. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs. Duration is measured by timing from the beginning of one contraction to the end of the same contraction. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. Elevations in human chorionic gonadotrophin decrease the need for insulin.Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction. Which of the following explains the primary rationale for insertion of chest tubes? A. The nurse is monitoring the progress of a client in labor. Maternal hyperreflexia D. 152. The nurse is aware that successful breastfeeding is most dependent on the: A. Which statement is true regarding the measurement of the duration of contractions? A. Duration is measured by timing from the end of one contraction to the beginning of the next contraction. B.Mother's educational level B.Mother's desire to breastfeed 153.Insulin requirements moderate as the pregnancy progresses.Fetal development depends on adequate insulin regulation. 155. The nurse is measuring the duration of the client's contractions. 157.Providing a calm environment B. C. The nurse should: A. Based on the client's age. Affected parents have a one in four chance of passing on the defective gene. B. At 1 minute. The nurse should explain that the doctor has recommended the test: A. Slow the infusion rate and turn the client on her left side D. age 32. A pregnant client.There is no need to take thyroid medication because the fetus's thyroid produces a thyroid-stimulating hormone. Respiratory distress syndrome C. 162.Bromocrystine (Pardel) 160. and the urinary output for the past hour is 100mL.Magnesium sulfate B.To detect neurological defects 163.Assessing fetal heart tones 158. Turner's syndrome D.) D. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. deep tendon reflexes are 1 plus. Stop the infusion of magnesium sulfate and contact the physician C.An affected newborn has unaffected parents. B. A client with a missed abortion at 29 weeks gestation is admitted to the hospital.Affected parents have unaffected children who are carriers. An affected newborn has one affected parent. To detect cardiovascular defects C.Pathological jaundice 159. is 6 weeks pregnant. The nurse's response is based on the knowledge that: A. age 42.Fetal growth is arrested if thyroid medication is continued during pregnancy.An apical pulse of 100 B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. A primigravida. her infant is at risk for: A. The nurse is responsible for performing a neonatal assessment on a full-term infant. the nurse could expect to find: A.C. D. The client will most likely be treated with: A. Cyanosis of the feet and hands . asks the nurse why her doctor has recommended a serum alpha fetoprotein. C. Because of her age D. Calcium gluconate C. Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders? A. A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80.Because it is a state law B. C. Administering an analgesic D. Dinoprostone (Prostin E.Down syndrome B.Continue the infusion of magnesium sulfate while monitoring the client's blood pressure B.Administer calcium gluconate IV push and continue to monitor the blood pressure 161. D. 164. An absence of tonus C. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism. 170. 16 pounds C.D. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? A. Antipyretics C. A client with diabetes has an order for ultrasonography. D.Nitroglycerin B. Alteration in elimination related to anesthesia D.24 pounds 168. The nonstress test: A. A gravida III para II is admitted to the labor unit. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The client with varicella will most likely have an order for which category of medication? A. The priority nursing diagnosis at this time is: A. Potential for injury related to precipitate delivery C. Shows the effect of contractions on the fetal heart rate D.Alteration in coping related to pain B. Ampicillin . The nurse should anticipate the client's need for: A.Supplemental oxygen B. 18 pounds D. B. Which statement describes hypospadias? A.The urethral opening is absent. Vaginal exam reveals that the client's cervix is 8cm dilated. C. A full-term male has hypospadias.Increasing fluid intake B.14 pounds B. with complete effacement. Administering an enema D. Limiting ambulation C.Antibiotics B. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The urethra opens on the dorsal side of the penis.Determines the lung maturity of the fetus B.Measures the neurological well-being of the fetus 169.Delivery by Caesarean section 166.Withholding food for 8 hours 167. A client is admitted complaining of chest pain.The urethra opens on the ventral side of the penis. Fluid restriction C.Jaundice of the skin and sclera 165. Antivirals D.Anticoagulants 172.Potential for fluid volume deficit related to NPO status 171. The penis is shorter than usual. Blood transfusion D. Which of the following drug orders should the nurse question? A. Measures the activity of the fetus C. Preparation for an ultrasound includes: A. Tachycardia and euphoric mood 177. Serve her small.Allow her in the unit kitchen for extra food whenever she pleases 180. Hallucinogenic drugs produce severe respiratory depression. Mylanta 30 ccs q 4 hours via NG C. 176. Right occipital anterior presentation C. Cimetadine 300mg PO q.Left occipital transverse presentation 178. Muscle cramping and abdominal pain D. Tachycardia and diarrhea C. The infant is most likely in which position? A. B. D. Take prescribed anti-inflammatory medications with meals. The nurse is aware that the doctor has ordered continuous observation because: A. 174. Alternate hot and cold packs to affected joints. the nurse should: A.Spasm of bronchiolar smooth muscle 179. To help her maintain sufficient nourishment. C. The nurse should give priority to assessing the client for: A. The primary physiological alteration in the development of asthma is: A. with the legs suspended at a right angle to the bed .Serve high-calorie foods she can carry with her B. Which of the following orders should be questioned by the nurse? A. D.Hips are resting on the bed. Encourage her appetite by sending out for her favorite foods C.i. B. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis? A.Avoid exercise because it fatigues the joints.Bronchiolar inflammation and dyspnea B. Left sacral anterior presentation D.Hallucinogenic drugs induce rapid physical dependence. Hallucinogenic drugs induce a state of altered perception.Depression and suicidal ideation B.Right breech presentation B. A client with mania is unable to finish her dinner. attractively arranged portions D.Morphine 8mg IM q 4 hours PRN pain 175.C. the nurse must make certain that the child's: A. To maintain Bryant's traction. A client with a history of abusing barbiturates abruptly stops taking the medication. the nurse notes that the FHT are loudest in the upper-right quadrant.Meperidine 100mg IM q 4 hours PRN pain B. Infectious processes causing mucosal edema D.Verapamil 173. A client with acute pancreatitis is experiencing severe abdominal pain.Hallucinogenic drugs create both stimulant and depressant effects. Propranolol D. D. C.d. The client is admitted to the chemical dependence unit with an order for continuous observation. Hypersecretion of abnormally viscous mucus C.Avoid weight-bearing activity. During the assessment of a laboring client. "I'm expressing milk from my breast.Cause changes in taste 187.B. Absence of eye movement D.Obtain a creatinine level 188. D.Refrain from keeping the diaphragm in longer than 4 hours B. Which action by the nurse indicates understanding of herpes zoster? A. Have the diaphragm resized if she gains 5 pounds D. The nurse is aware that the nurse should contact the lab for them to collect the blood: A.The nurse administers oxygen. Cause mental confusion D. 1 hour after the infusion D. C. Which nursing intervention is most critical during the administration of acyclovir? . B." C. 182. Damage to the VII cranial nerve results in: A. "I'm drinking four glasses of fluid during a 24-hour period. Keep the diaphragm in a cool location C.Tinnitus 186. The client using a diaphragm should be instructed to: A. Absence of ability to smell C. The nurse wears gloves when providing care. with the traction positioned at the foot of the bed 181. The client should be taught that the medication may: A. 30 minutes before the infusion C. I'll allow the water to run over my breasts. Change the color of her urine C.Facial pain B." D.The nurse covers the lesions with a sterile dressing.Check the calcium level B. A client with AIDS is taking Zovirax (acyclovir).Hips and legs are flat on the bed. The nurse administers a prescribed antibiotic. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed C." 185.2 hours after the infusion 183. Perform a pregnancy test C. The client has an order for a trough to be drawn on the client receiving Vancomycin."I'm wearing a support bra.Have the diaphragm resized if she has any surgery 184.15 minutes after the infusion B.Cause diarrhea B. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed D."While I'm in the shower. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Monitor apical pulse D. A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection." B. Which of the following tests should be performed before beginning a prescription of Accutane? A. Which of the client's statements indicates the need for additional teaching? A. Dilate the pupils C. Which of the following indicates that the client has experienced toxicity to this drug? A. D. The nurse should administer this medication: A. B. C. A client with a severe corneal ulcer has an order for Gentamycin gtt.Paralyze the muscles of accommodation 195. The medications may be used together. q 4 hours and Neomycin 1 gtt q 4 hours.Changes in vision B. A client is admitted for an MRI. Encourage a high-carbohydrate diet C.Inability to move his feet 190. Three times per day with meals C.Anesthetize the cornea B. Cataracts result in opacity of the crystalline lens. 196.Pregnancy B.Encourage fluids 189. The lens focuses light rays on the retina. Constrict the pupils D.The medications should not be used in the same client. The client with hypertension being maintained on Lisinopril C.Changes in skin color 191. The nurse should visit which of the following clients first? A.The lens magnifies small objects. 194. Which of the following best explains the functions of the lens? A. C. The nurse should question the client regarding: A. A client who has glaucoma is to have miotic eyedrops instilled in both eyes.Once per day in the morning B. A titanium hip replacement C.The lens controls stimulation of the retina. Which of the following schedules should be used when administering the drops? A. A client with cystic fibrosis is taking pancreatic enzymes. Nausea C. Utilize an incentive spirometer to improve respiratory function D.The client with Raynaud's disease 192. D. Urinary frequency D. The client with chest pain and a history of angina D. The medications should be separated by a cycloplegic drug. Allergies to antibiotics D.Limit the client's activity B. The lens orchestrates eye movement.Four times per day 193. The nurse knows that the purpose of the medication is to: A.The client with diabetes with a blood glucose of 95mg/dL B.A. The nurse is caring for the client receiving Amphotericin B. The client with color blindness will most likely have problems distinguishing which of the following colors? .Allow 5 minutes between the two medications. Once per day at bedtime D. B. Refrain from using a microwave oven D.White 197.Treat anemia. D. A client with pneumacystis carini pneumonia is receiving trimetrexate.60 minutes after meals . The nurse should advise the client to refrain from drinking after: A.A. rabbits. Increase the number of white blood cells.1900 B.Reverse drug toxicity. A client tells the nurse that she is allergic to eggs.Report ankle edema B."I can save my dessert from supper for a bedtime snack. C.30 minutes before meals B. dogs. 1200 C. Violet C.0700 199. Red D. Which of the following diet instructions should be given to the client with recurring urinary tract infections? A. The nurse should administer the medication: A. 200."I will make sure I eat breakfast within 2 hours of taking my insulin. D. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to: A. 1000 D." D. Check his blood pressure daily C.TB skin test B. 202.Chest x-ray 203. With each meal C. The client with enuresis is being taught regarding bladder retraining. ELISA test D.Monitor his pulse rate 198. The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. B. The client with a pacemaker should be taught to: A. C. B." B. Avoid citrus fruits. In a single dose at bedtime D.Orange B. "I will need to carry candy or some form of sugar with me all the time. Which statement indicates that the client knows when the peak action of the insulin occurs? A. Rubella vaccine C. Perform pericare with hydrogen peroxide." 201. Create a synergistic effect." C.Drink a glass of cranberry juice every day. Which order should the nurse question? A. The physician has prescribed NPH insulin for a client with diabetes mellitus. and chicken feathers.Increase intake of meats. "I will eat a snack around three o'clock each afternoon. C. Based on this finding.Colorful crib mobile B.Visual disturbances can be corrected with prescription glasses. While assessing the postpartal client. Assess the blood pressure for hypotension C. A client on the postpartum unit has a proctoepisiotomy. The nurse is aware that the proximal end of a double barrel colostomy: A. An MRI should not be done if the client has: A. A schedule of strenuous exercise will improve muscle strength.Taking a hot bath will decrease stiffness and spasticity. To develop a teaching plan. 209. Total Parenteral Nutrition cannot be managed with oral hypoglycemics. Methyergonovine maleate (Methergine) D.Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels. The nurse is preparing to discharge a client with a long history of polio. An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. The doctor has ordered for sliding-scale insulin.Is the opening on the distal right side 205.Sensory deafness 207. The physician has ordered an MRI for a client with an orthopedic ailment. Which toy is best suited to the client? A. B. The nurse should tell the client that: A.The need for oxygen therapy B.Ask the client to void B.Bromocriptine sulfate (Parlodel) 210. the nurse notes that the fundus is displaced to the right. A history of claustrophobia C. the nurse should initially assess: . D. D.30-piece jigsaw puzzle 208. The most likely explanation for this order is: A. Hand-held electronic games C. A permanent pacemaker D.204. A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). Cars in a plastic container D.Dulcolax suppository B. C. Rest periods should be scheduled throughout the day. 211.Total Parenteral Nutrition leads to further pancreatic disease. Administer oxytocin D. Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.Is the opening on the client's left side B.Check for vaginal bleeding 206. The nurse should anticipate administering which medication? A. B. Docusate sodium (Colace) C. A 6-month-old client is placed on strict bed rest following a hernia repair. Is the opening on the client's right side D. the nurse should: A. A temporary colostomy is performed on the client with colon cancer. Is the opening on the distal end on the client's left side C. A client with bladder cancer is being treated with iridium seed implants. Surgery with Kirschner wire implantation D. An obstetric client is admitted with dehydration. Eliminate circulating Rh antibodies D. Tell the client he will be asleep D.Assess the client for allergies B. A laser to smooth and reshape the lens . Which IV fluid would be most appropriate for the client? A. The nurse understands that RhoGam is given to: A.Insert a urinary catheter 214.Antivirals B.The client's thought about future children 212. Bolus the client with IV fluid C. The physician has ordered an injection of RhoGam for a client with blood type A negative. Dextrose 1% in water C. Which treatment should the nurse anticipate for the fractured foot? A. Which category of medication prevents the formation of antibodies against the new organ? A. Before the procedure. Immunosuppressants D. The physician has ordered a thyroid scan to confirm the diagnosis.Convert the Rh factor from negative to positive 215. The nurse is aware that the procedure will use: A. Following a heart transplant. The nurse is preparing a client for cataract surgery.45 normal saline 213.A.Dextrose 5% in . Report urinary frequency D.Application of a short inclusive spica cast B.Strain his urine B.The client's knowledge of the signs of preterm labor B. Increase his fluid intake C. the nurse should: A. The client's feelings about the pregnancy C. Whether the client was using a method of birth control D. Prevent the formation of Rh antibodies C. Miotic medications such as Timoptic C. The nurse is caring for a client admitted to the emergency room after a fall.Avoid prolonged sitting 217.A gauze dressing only 216. Lactated Ringer's D.45 normal saline B. a client is started on medication to prevent organ rejection. The nurse's discharge teaching should include telling the client to: A. X-rays reveal that the client has several fractured bones in the foot.Analgesics 218. Stabilization with a plaster-of-Paris cast C. Antibiotics C..Mydriatics to facilitate removal B.Provide immunity against Rh isoenzymes B. The nurse is aware that the most likely cause for the deduction of one point is: A. B. A client is brought to the emergency room by the police.Keep the common bile duct open 221.Label the existing bottle with the current date and time 225. Placing simple signs to indicate the location of the bedroom. Ask the ward secretary when the solution was requested D. Obtain a new bottle and label it with the date and time of first use C. Dizziness D.D. Scrotal rugae C. The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation.Mongolian spots B.Prevent the need for dressing changes B.The client is intoxicated. "I have to get out of here. The chief purpose of the Jackson-Pratt drain is to: A.Hematuria B. They are trying to kill me. B. D. The baby's hands and feet are blue. An infant's Apgar score is 9 at 5 minutes. The nurse is caring for a client admitted with multiple trauma.The client is experiencing an auditory hallucination. Which long-term plans would be most therapeutic for the client? A. Placing a picture of herself in her bedroom C. The client is having a delusion of grandeur. Which finding should be reported to the physician immediately? A. He is combative and yells. D.Silicone oil injections into the eyeball 219. The nurse is preparing to suction the client with a tracheotomy.Alternating healthcare workers to prevent boredom 220.Lip the bottle and use a pack of sterile 4x4 for the dressing B. The nurse can expect to find the presence of: A. Reduce edema at the incision C. Muscle spasms C. and ulna.Vernix caseosa 222. Fractures include the pelvis.Placing mirrors in several locations in the home B. The client is experiencing paranoid delusions.Nausea 223. femur. 224. The nurse notes a previously used bottle of normal saline on the client's bedside table.The baby is lethargic. Head lag D. The nurse should: A. A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. and so on D. The baby is experiencing bradycardia." Which assessment is most likely correct in relation to this statement? A. C. A client with an abdominal cholecystectomy returns from surgery with a JacksonPratt drain.The baby is cold. bathroom. There is no label to indicate the date or time of initial use. C. Provide for wound drainage D. . the doctor will remove the: A. and a gown. "The pain is psychological because your foot is no longer there. Which response by the nurse indicates understanding of phantom limb pain? A." 231. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions.226. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Transmission is highly likely. The client should be taught to avoid eating: A.Infection requires skin-to-skin contact and is prevented by hand washing. so the client should wear a mask at all times. Administer an antiviral D. I will get you some pain medication.Tell the client that he should remain in isolation for 2 weeks 229." C.Fruits B. Stomach and duodenum D. Promote movement D. Salt C.Head of the pancreas B.Prevent pain and discomfort 227. 230. Which statement is true regarding precautions for infections spread by contact? A. B. A client with cancer of the pancreas has undergone a Whipple procedure. therefore. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by: A.Filtering waste through a dialyzing membrane 228. The nurse is aware that during the Whipple procedure. The primary reason for rapid continuous rewarming of the area affected by frostbite is to: A. Pepper D. The physician has ordered a minimal-bacteria diet for a client with neutropenia."The pain and itching are due to the infection you had before the surgery. the door may remain open. Lowering the pH by removing nonvolatile acids D. D. Eliminating plasma proteins from the blood C. During a home visit. Which action by the nurse is most appropriate? A. Contact the physician for an order for immune globulin C.Passing water through a dialyzing membrane B."The pain will go away in a few days. C. Infection requires close contact. a client with AIDS tells the nurse that he has been exposed to measles.Administer an antibiotic B." B.Ketchup .The client should be placed in a room with negative pressure. gloves." D.Esophagus and jejunum 232. "The pain is due to peripheral nervous system interruptions.Lessen the amount of cellular damage B. Proximal third section of the small intestines C. Prevent the formation of blisters C. The client should be told to avoid: A. To facilitate removal. Epinephrine C.233. The client should be instructed to: A. The nurse is assisting the physician with removal of a central venous catheter. Eat more fruits and vegetables C. place an X on the Tail of Spence. deep breaths as the catheter is removed D. The infant is admitted to the unit with tetrology of falot. D.Have a Protime done monthly B. The nurse would anticipate an order for which medication? A. The nurse is educating the lady's club in self-breast exam. the nurse should instruct the client to: A.Notifying the physician 239. The nurse is changing the ties of the client with a tracheotomy. 238. A history of streptococcal infections C. the nurse should assess the client for: A. The nurse is aware that most malignant breast masses occur in the Tail of Spence. A client is discharged home with a prescription for Coumadin (sodium warfarin). The intake of salt D.Perform the Valsalva maneuver as the catheter is advanced B.Turning the client to the left side B. The hourly output from the chest tube was 300mL. Prior therapy with phenytoin D. A client has an order for streptokinase. C. Have a helper present. Milking the tube to ensure patency C. The safest method of changing the tracheotomy ties is to: A. On the diagram. Take slow.Apply the new tie before removing the old one.Allergies to pineapples and bananas B. Hold the tracheotomy with the nondominant hand while removing the old tie. Drink more liquids D.Avoid crowds 234. Slowing the intravenous infusion D.A history of alcohol abuse 236. The nurse is providing discharge teaching for the client with leukemia. B.Digoxin B. The nurse should give priority to: A.Turn his head to the right while maintaining a sniffing position 235. The nurse is monitoring a client following a lung resection.Using an electric razor 237.or cream-based soaps B.Atropine 240. Before administering the medication.Ask the doctor to suture the tracheostomy in place. Flossing between the teeth C. Aminophyline D. Turn his head to the left side and hyperextend the neck C.Using oil. . Measure the well-being of the fetus 243. The nurse is monitoring a client with a history of stillborn infants. The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. Measure the fetal activity C.241. Show the effect of contractions on fetal heart rate D. The nurse is aware that a nonstress test can be ordered for this client to: A.Instruct the client to push B. The nurse is aware that the infant with a ventricular septal defect will: A. The toddler is admitted with a cardiac anomaly. Need more calories D.Determine lung maturity B. Grow normally C.Be more susceptible to viral infections 242. Perform a vaginal exam . Which action should be taken first by the nurse? A. The following graph is noted on the monitor.Tire easily B. Be injected into the abdomen C. Feeding the client with dementia D. The nurse should teach the client that Lovenox injections should: A. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. Obtain a urinalysis monthly D.Question the order because they cannot be given at the same time 247. wait 5 minutes. Emptying the Foley catheter of the preeclamptic client C. The nurse should teach the client to: A. A sinus rhythm C. A padded tongue blade C.Atrial flutter B.C. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. Turn off the Pitocin infusion D.Placing the client in seclusion B. The client has recently returned from having a thyroidectomy. Aspirate after the injection D.Ambulating the client with a fractured hip 249. The nurse would evaluate the cardiac arrhythmia as: A.A tracheotomy set B. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. Administer the medication separately C.Clear the air from the syringe before injections 246. The nurse should keep which of the following at the bedside? A. Which task should be assigned to the nursing assistant? A.Atrial fibrillation 245.Douche after intercourse B.Place the client in a semi-Fowler's position 244. The correct method of administering these medications is to: A.Be injected into the deltoid muscle B.Wipe from back to front after voiding 248.Administer the medications together in one syringe B.An airway . and then inject the Phenergan D. The nurse notes the following on the ECG monitor. Ventricular tachycardia D. Void every 3 hours C. An endotracheal tube D. Administer the Valium. and sensation would not give information regarding peripheral circulation. therefore. 2. Body temperature. The physician has ordered a histoplasmosis test for the elderly client. motion. and C are incorrect. answers A.250. Therefore. Answer B is correct. B.Birds Answers and Rationales for Comprehensive Examination Part 2 1. Flexion of the hips and knees. 3. Answer D is correct. Turtles D. Cats B. impedes circulation and is not correct positioning for this client. Answer C is incorrect because raising the knee gatch impedes circulation. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. B. answers A. The nurse is aware that histoplasmosis is transmitted to humans by: A. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis. which includes the knee-chest position. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Answer D is correct. . Dogs C. and C are incorrect. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Answers A. and airplane travel can cause sickling episodes and should be avoided. A family vacation in the Rocky Mountains at high altitudes. Answer C is correct. and D are incorrect. 12. B. Petechiae are not usually visualized on dark skin. 9. Radiation treatment for other types of cancer can result in leukemia. it would not require a bolus. 8. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation. Answer D is correct. raisins. Therefore. but the side dishes accompanying these choices are not. Bleeding. Answers B. 5. making answer B incorrect. 6. but not the ones in these answers. Answer A is correct. Popsicles. there is less hemoglobin and less oxygen. which give a yellowish hue. the shins would be an area of darker pigment. and blood pressure changes do not occur. C. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling. cold temperatures. the pulse oximetry indicates that oxygen levels are low. has weight loss. the client is often short of breath. 13. as indicated in answer B. However. leafy vegetables are all high in iron. cabbage. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling. The foods in answers A. Taking a trip to the museum is the only answer that does not pose a threat. so answer D is incorrect. Answers A. and a diet low in iron is essential to preventing further red cell formation. incorrect. therefore. Answer C is correct. so examining the tongue should be included in the physical assessment. The most prominent clinical manifestation of sickle cell crisis is pain. which is an important mineral for this client. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. answer A is incorrect. therefore. answers A and B are incorrect. thus. The client with polycythemia vera is at risk for thrombus formation. and may be hypotensive. The conjunctiva can have normal deposits of fat. answers A. it would not be a priority. oxygenation takes precedence over pain relief. B. Answer D is correct. carrots. Answer B is correct. . and green. B. therefore. and C incorrect. and pork chops are also high in iron. Support hose promotes venous return. therefore. the electric razor prevents bleeding due to injury. and C are incorrect. The soles of the feet can be yellow if they are calloused. are incorrect. and D are within normal and. Hydration is important in the client with sickle cell disease to prevent thrombus formation. making answers A. wheat bread. Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency. thus. Answer B is incorrect because although hydration is important. and pudding have high fluid content. 10. and D are incorrect because they all contribute to the prevention of complications. splenomegaly. Egg yolks. 7. and C are incorrect because the skin might be too dark to make an assessment. answers A. Roast beef. 11. B. Answer C is correct. The client with anemia is often pale in color. Some hobbies and occupations involving chemicals are linked to leukemia. juice. Answer C is correct. and D do not aid in hydration and are. gelatin. so the statement to drink less than 500mL is incorrect. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. therefore. B. Answer C is correct. When there are fewer red blood cells. C.4. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings. but platelets do not carry oxygen. C. and D are incorrect. 21. C. and any injury would exacerbate the problem. and D are incorrect. 16. 18. The priority is to prevent and minimize bleeding. and D are incorrect. The loss of electrolytes would be reflected in the vital signs. therefore. and D are incorrect because Trendelenburg. The tingling is due to low calcium levels. 19. White cell counts. 22. and D are incorrect. and specific gravity changes occur with other disorders. and D are incorrect because they are of lesser priority. The crash cart would be needed in respiratory distress but would not be the next action . and coughing all increase the intracranial pressure. 23. Answer C is correct. Oxygenation in answer C is important. Temperature would be an indicator of infection. Measuring the urinary output is important. 24. Answer B is correct. Valsalva maneuver. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. which are incorrect. Answer B is correct. B. C. Hodgkin’s disease. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. and D.000–400. and daily weights is unnecessary. Answer A is correct. The psychosocial needs of the client are important to address in light of the age and life choices. weight loss. Answers B. potassium levels. answers A. therefore. answers B. The client with acute leukemia has bleeding tendencies due to decreased platelet counts. Answer A is correct. 15. The normal platelet count is 120. Answer A is correct. Answers A. answers B. C. Answer B is correct. Answer B is correct. and D are incorrect because direct pressure to the nose stops the bleeding. Answer A is correct. however. which is of higher priority than the diagnoses in answers A. The client would require close monitoring for hemorrhage. Insomnolence. Bleeding occurs in clients with low platelets. but bleeding tendencies and infections are the primary clinical manifestations. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts. 20. so answer A is incorrect.000. therefore. sodium and potassium levels would be monitored when the client is receiving mineral corticoids. 17. the nares are loosely packed. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. to prevent aspiration of blood. If a pack is necessary. and ice packs should be applied directly to the nose as well. Answer C is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin.14. Answer A is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. answers B. The client should be positioned upright and leaning forward. B. has a good prognosis when diagnosed early. Answers B and D are of lesser priority and are incorrect in this instance. thus. C. making answer C incorrect. The remaining gland might have been suppressed due to the tumor activity. and PTT are not affected in ATP. and a decrease in alertness also occur in leukemia. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Answer D is incorrect because weighing the client is not necessary at this time. Encouraging fluid intake will not correct the problem. Answers A. Answer B is not necessary at this time. but the stem already says that the client has polyuria. C. making answer A the correct answer. decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes. Liver. B. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage. The medication should be taken sublingually and should not be crushed. Answer A is correct. particularly grapefruit. answer D is incorrect. not after the fact. A paper tape measure should be used rather than one of plastic or cloth. 27. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line. B. so answer B is incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer. as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil. or contact the pharmacy. The other parts of the body will be edematous in right-sided congestive heart failure. thus. The client should be placed in dorsal recumbent position. 30.and water-tight. and D are incorrect. making answer C incorrect. cheese. beef. thus. so answer B is incorrect. C. The best indicator of peripheral edema is measuring the extremity. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answer B is correct. making answer C incorrect. 26. light. not 3 months. thus. The supply should be replenished every 6 months. and . Answer C is correct. Hyperstat is given IV push for hypertensive crises. eggs. as stated in answer D.to take. C. so answers C and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking. Turkey contains the least amount of fats and cholesterol. answer A is incorrect. Answer B is correct. Erb’s point is the point at which you can hear the valves close simultaneously. but it often causes hyperglycemia. solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air. and D are incorrect. Answer C is correct. 31. 34. Answer B is correct. not left-sided. therefore. The jugular veins in the neck should be assessed for distension. answers A. Nitroglycerine should be kept in a brown bottle (or even a special air. and D are incorrect. The glucose level will drop rapidly when stopped. administer the medication separately. not a Trendelenburg position. and D are incorrect because the order is accurate. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. and respirations are within normal limits. 33. There is no need to question the order. 32. and C are incorrect. the client should report to the emergency room. Answer A is correct. The blood glucose. cream sauces. thus answers A. 29. B. making answer D incorrect. answers A. 25. or water. and one tablet should be taken every 5 minutes until pain subsides. Answer B is correct. The decrease in pulse can affect the cardiac output and lead to shock. can decrease the effectiveness. A heart rate of 60 in the baby should be reported immediately. shrimp. Answers A. The medication should be taken with water because fruit juice. which would take precedence over the other choices. The dose should be held if the heart rate is below 100bpm. and chocolate should be avoided by the client. Answer D is correct. The medication takes effect within 1 month of beginning therapy. If the pain does not subside. Liver function studies should be checked before beginning the medication. Answer A is incorrect because the hyperstat is given by IV push. 28. answers A. so answers A and B are incorrect. Answer C is correct. thus. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. blood pressure. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Answers A. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. so answer A is incorrect. so food should be available within 10–15 minutes of taking the insulin. 41. Proton pump inhibitors such as Nexium and Protonix should be taken with meals. they are incorrect. 43. Answer B is correct. Answer D does not treat the problem adequately and. A low-grade temperature. blood-tinged sputum. increase neutrophils. they are not the primary answer to the question. Answer C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Teaching the family member these principles is extremely important. C. The answers in B. as stated in answer C. Answer B does not address a particular type of insulin. if necessary. answer A would have been consistent with the symptoms . Answer B is incorrect because simply telling the client to calm down will not work. Answers B. C. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.m. The client with a facial stroke will have difficulty swallowing and chewing. NPH insulin peaks in 8–12 hours. Answer A is correct. and D are incorrect because these vaccines are given later in life. and C are incorrect because Leucovorin does not treat iron deficiency. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. B. 37. 35. The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals. fatigue. 42. Answer A is correct. C. so it is incorrect. is incorrect. and using lead to shield against the radium. putting distance between people and the radium source. Answer D is incorrect because there is no need to save the dessert until bedtime. Answer A is incorrect because weighing the client will not indicate peripheral edema. Tagamet can be taken in a single dose at bedtime. The general rule is limiting time spent exposed to radium. The foods in answers A. or have a synergistic effect. and night sweats are symptoms consistent with tuberculosis. It may not be 3 p. Answers A. C.the area should be marked with a pen. 39. If the answer in A had said pneumocystis pneumonia. Answer B is correct. making answer C incorrect. 38. Answer D is correct. Novalog insulin onsets very quickly. and D would require more chewing and. are incorrect. Answer C is correct. The next action by the nurse should be to check for bladder distention and catheterize. 40. and D are actions that relate to postpartal hemorrhage. for optimal effect. providing the most objective assessment. 44. 36. this might indicate a full bladder. therefore. Answer A is correct. If the fundus of the client is displaced to the side. so a snack should be eaten at the expected peak time. Leucovorin is a folic acid derivative. Answer A is correct. Although answers A. therefore. Answer D is incorrect because if the client is left alone he might harm himself. and D might be important. thus. Answer B is correct. and C are not empathetic and do not address the question. B. and the foods in answer B provide the least amount of chewing. given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem. 45. Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect. 46. Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign. 47. Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect. 48. Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect. 49. Answer C is correct. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion. 50. Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect. 51. Answer B is correct. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect. 52. Answer B is correct. The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect. 53. Answer B is correct. A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Condylomata lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea does not present as a lesion, but is exhibited by a yellow discharge. 54. Answer C is correct. Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis, so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea, so answer D is incorrect. 55. Answer D is correct. The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer C is incorrect. 56. Answer A is correct. Answer B elicits the triceps reflex, so it is incorrect. Answer C elicits the patella reflex, making it incorrect. Answer D elicits the radial nerve, so it is incorrect. 57. Answer B is correct. Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so they are incorrect. 58. Answer C is correct. When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer D is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, making answer B incorrect. 59. Answer C is correct. Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers A, B, and D are incorrect. 60. Answer B is correct. The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers A, C, and D are incorrect. 61. Answer D is correct. If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B, the IV rate should be increased, not decreased. In answer C, the oxygen should be applied by mask, not cannula. 62. Answer A is correct. Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus, answers B, C, and D are incorrect. 63. Answer C is correct. Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus, answer D is incorrect. 64. Answer B is correct. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect. 65. Answer A is correct. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Answers B, C, and D are not factors for concern. 66. Answer D is correct. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions. 67. Answer B is correct. In clients who have not had surgery to the face or neck, the answer would be answer A; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time. 68. Answer C is correct. If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers A, B, and D are not the first action to be taken. 69. Answer A is correct. The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B, C, and D may be needed at a later time but are not the most important actions to take first. 70. Answer C is correct. The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately 400mg of calcium. 71. Answer C is correct. The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary, so answers A, B, and D are incorrect. 72. Answer D is correct. If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, so answers B and C are incorrect. 73. Answer B is correct. The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, as well as hyponatremia and hypokalemia in C and D, but these answers are not of primary concern so are incorrect. 74. Answer D is correct. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat, so answer A is incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, answer B is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so answer C is incorrect. 75. Answer D is correct. At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, Answers A, B, and C are incorrect. 76. Answer B is correct. It is normal for the client to have a warm sensation when dye is injected. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect. 78. so answers B. the client will have a grand mal seize. The clients in answers B. Answer A is correct. Answer D is correct. Answer D is correct. The entire family should be treated to ensure that no eggs remain.000 eggs. Answers A. Answers A. C. The healthcare workers in answers A. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. and assault is a violent physical or verbal attack. There is no need to scrap the skin. 82. 79. so the client is not radioactive. and C do not indicate that the ECT has been effective. Asking the client how he feels in answer C . 80. is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). B. Giving the infant an overdose falls into this category. Negligence is failing to perform care for the client. In answer B. These clients are radioactive in very small doses. Because a single treatment is usually sufficient. Answer D is correct. and C are incorrect because they apply to other wrongful acts. C. If the client has active infection with methicillin-resistant staphylococcus aureus. This increase in the level of cortisone causes the client to be immune suppressed. The licensed practical nurse should not be assigned to begin a blood transfusion. a tort is a wrongful act committed on the client or their belongings. therefore. especially upon returning from the procedures. Answer B is correct. The client with Cushing’s disease has adrenocortical hypersecretion.77. The client in answer C has an increase in growth hormone and poses no risk to himself or others. Answer D is correct. The eggs hatch in the upper intestine and mature in 2–8 weeks. The client in answer D has hyperthyroidism or myxedema and poses no risk to others or himself. so are incorrect. and C are incorrect. Continuing to monitor the vital signs can result in deterioration of the client’s condition. The vital signs are abnormal and should be reported immediately. This indicates completion of the electroconvulsive therapy. It is not necessary to wear gloves to take the vital signs of the client. During ECT. Answer A is correct. C. The family should then be tested again in 2 weeks to ensure that no eggs remain. The females then mate and migrate out the anus. and D are incorrect. where they lay up to 17. The nurse could be charged with malpractice. The specimen should then be brought in to be evaluated. This causes intense itching. there is usually good compliance. Erterobiasis. 83. Answer A is correct. which is failing to perform. Infection with pinworms begins when the eggs are ingested or inhaled. and C indicate knowledge of infection control by their actions. Answers A. B. The client receiving linear accelerator therapy travels to the radium department for therapy. Answer B is correct. B. and collect sputum specimen. 84. 81. 85. collect a stool specimen. or pinworms. answers A. The licensed practical nurse can insert a Foley catheter. gloves should be worn. and D are incorrect statements. For approximately 72 hours. B. The radiation stays in the department. or bring a sample of hair. or performing an act that causes harm to the client. making answer A incorrect. discontinue a nasogastric tube. the client with diabetes poses no risk to other clients. the clients should dispose of urine and feces in special containers and use plastic spoons and forks. The pregnant nurse should not be assigned to any client with radioactivity present. and D pose a risk to the pregnant nurse. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. Answer A is correct. 86. Answer D is correct. is not necessary. Always remember your ABCs (airway. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. as in answer D. dry place. as ordered. The clients in answers A. Answer B is correct. Although the mother of the child can instill the eyedrops. so answer D is incorrect. The nurse should encourage rooming-in to promote parent-child attachment. but these are not the first actions requested in the stem. and the nurse in answer D is not the best nurse to assign because this client is unstable. and the nurses in answers C and D have no experience with the postpartum client. and D need to be placed in separate rooms due to the serious natures of their injuries. Although answers B and D might be appropriate for this . answers A and B are incorrect. circulation) when selecting an answer. Answers A. so answer A is incorrect. the nurse should instill the eyedrops. breathing. The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. C. 90. a grilled cheese sandwich. but is not of interest to the Joint Commission. Changing the batteries weekly. Answer C is correct. B. The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. the nurse should cleanse the area with water. Answer B is correct. Answer B is correct. The others are more stable. The hearing aid should be stored in a warm. Although the eye might appear to be clear. Before instilling eyedrops. 92. The failure of the nursing assistant to care for the client with hepatitis might result in termination. the area must be cleansed before administration. and ice cream do not pose a risk of aspiration for a child. 89. 95. Answers A. so answer B is incorrect. therefore. making answer C incorrect. It should be cleaned daily but should not be moldy. Answer D is not part of the nurse’s responsibilities. Remember the ABCs (airway. It is okay for the parents to be in the room for assessment of the child. C. Answer B is correct. making answer C incorrect. the toothpick might break off in the hearing aide. 94. The clients in answers A. circulation) when answering this question. the nurse may be terminated and reported to the Board of Nursing. MRSA is methicillin-resistant staphylococcus aureus. A toothpick is inappropriate to use to clean the aid. 93. Answer C is correct. Allowing the child to have items that are familiar to him is allowed and encouraged. breathing. 91. and D are incorrect. Answer C is correct. Therefore. The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. 87. 88. and C are more stable and can be seen later. A 6-year-old child is not developmentally ready to instill his own eyedrops. The nurse in answer A is a new nurse to the unit. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Answer C is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. B.will only provide subjective data. The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. Answer B is correct. and C are incorrect because white grape juice. If the behavior continues or if harm has resulted to the client. The normal oxygen saturation for a child is 92%–100%. so answers A and C are incorrect. 96. Answer B is correct. Answer A is a vague answer. so answers C and D are incorrect. The client with hyperthyroidism will often exhibit tachycardia. Answer A is not indicated at this time. Bacterial pneumonia usually presents with a productive cough. Answer B is correct. B. Before notifying the physician or assessing the pulse. 106. An internal monitor can be applied if the client is at 0-station. Cervical effacement is caused by pressure on the presenting part. Answer C is not the best action for clients experiencing bradycardia. Remember the ABCs (airway. 102. Answer C is correct. C. B. 97. Answer B is correct. Answers A. The first action would be to turn the client to the left side and apply oxygen. Answer A is correct. If the nurse notes the umbilical cord. and C all contain gluten. circulation) when answering this question. 104. and D are incorrect. and oxygen will not treat an obstruction. breathing. which can increase the pain. Applying a fetal heart monitor is the correct action at this time. so answer B is incorrect. 105. Answer C is opposite the action of Pitocin. answers A. answer B indicates the end of the first stage of labor. If the child has bacterial pneumonia. making answer B incorrect. answers A. Contraction intensity has no bearing on the application of the fetal monitor. making answer B incorrect.child. Answer D is correct. There is no data to indicate the need to move the client to the delivery room at this time. Answer B is correct. 99. and weight loss. Answer C is correct. the client is experiencing a prolapsed cord. 103. Answer D is correct. Answer B is correct. Dilation of 2cm marks the end of the latent phase of labor. Fetal heart tones of 160 indicate tachycardia. emergency tracheostomy equipment should always be kept at the bedside. Pitocin causes more intense contractions. while answer D gives the only choice of foods that does not contain gluten. therefore. so answer D is incorrect and would need to be reported immediately. oxygen should be applied to increase the oxygen saturation. There is no need to prepare for a Caesarean section or to place the client in Genu Pectoral position (knee-chest). if necessary. and answer C indicates the transition phase. making answer A incorrect. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. and vomiting and diarrhea are usually not seen with pneumonia. so answers A and D are incorrect. not a nonproductive cough. Answer A does not apply for a child who has undergone a tonsillectomy. and greenish fluid is indicative of meconium. Rhinitis is often seen with viral pneumonia. 101. 100–110bpm is bradycardia. therefore. The normal fetal heart rate is 120–160bpm. The child with celiac disease should be on a gluten-free diet. answer C should have the highest priority. a high fever is usually present. 98. An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. For a child with epiglottis and the possibility of complete obstruction of the airway. Intravenous supplies. and D are incorrect. Answers A. and D are incorrect. The expected effect of Pitocin is cervical dilation. Answer D is correct. The cervix is dilated enough to use an internal monitor. Answer D is incorrect because there is no need for an ultrasound based on the finding. The nurse decides to apply an external monitor because the membranes are intact. 100. . C. fluid. so answers A and C are incorrect. increased appetite. 113. Therefore. The best method of birth control for the client with diabetes is the diaphragm. and D are incorrect. Administering oxygen is also indicated. B. making answers A. The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. B. It is not dependent on the age of the client. and D are incorrect. stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Answers A. At about day 14.107. Answers B and C are not correct in relation to the stem. B. The client will complain of sudden. Answer C is correct. and answer C is indicative of an early deceleration. Lutenizing hormone released by the pituitary is responsible for ovulation. B. 116. Answer B is not necessary at this time. Answer D is correct. B. 114. Answer D is incorrect because there is no data to indicate that the monitor has been applied incorrectly. Answer A has no relation to the readings. so it’s incorrect. Answer B contains the potato chips. and D are incorrect for the stem. Answer A is lacking in fruits and milk. C. to avoid nausea and vomiting. the left side. and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy. Answer D is correct. 112. This type of deceleration is caused by uteroplacental lack of oxygen. oral contraceptives tend to elevate blood glucose levels. Epidural anesthesia decreases the urge to void and sensation of a full bladder. In answer A. Answer C contains meat. Answer B is correct. Answers A. therefore. Answer C is correct. A full bladder will decrease the progression of labor. 115. The LH surge is responsible for ovulation. Answer D is correct. This information indicates a late deceleration. not thin. . Painless vaginal bleeding is a sign of placenta previa. frequency of intercourse. answer B results in a variable deceleration. answers A. The initial action by the nurse observing a late deceleration should turn the client to the side—preferably. Ice chips may be allowed. Accelerations with movement are normal. 110. the endometrial lining is thick. which occurs within the next 10–12 hours after the LH levels peak. Answer C is correct. Answer C is correct. impaired gas exchange related to hyperventilation would be indicated during the transition phase. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided. potato salad. 109. and D are incorrect because estrogen levels are high at the beginning of ovulation. Answer C is correct. Clients admitted in labor are told not to eat during labor. Answers A. 111. and C incorrect. or range of the client’s temperature. and C indicate ominous findings on the fetal heart monitor. 108. answers A. but the pregnant client needs a diet that is balanced and has increased amounts of calcium. and contraceptive sponges are not good at preventing pregnancy. Answer A might be necessary but not before turning the client to her side. abdominal cramping is a sign of labor. the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. but this amount of fluid might not be sufficient to prevent fluid volume deficit. Answer D is correct. not low. fruit. which has about 360mg of calcium. and yogurt. All of the choices are tasty. Answer D is not the best diet because it lacks vegetables and milk products. and the progesterone levels are high. which contain a large amount of sodium. The success of the rhythm method of birth control is dependent on the client’s menses being regular. or the release of the dominant follicle in preparation for conception. so answers A and B are incorrect. but not with appropriate size for gestation. glucose levels fall rapidly due to the absence of glucose from the mother.117. and D are subjective and might be related to other medical conditions. RhoGam should be given within 72 hours. When the client is taking oral contraceptives and begins antibiotics. Answer C is correct. Answer D is incorrect because the infant will be large. therefore. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. Answer B is correct. The clients in answers A. 122. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should not wait until the contractions are every 2 minutes or until she has bloody discharge. Cervical check for dilation is contraindicated because this can increase the bleeding. and D are incorrect. The client with hyperemesis has persistent nausea and vomiting. Preterm births are associated with smoking. not small. The symptoms of painless vaginal bleeding are consistent with placenta previa. Answer A is correct. 119. 125. After birth. 120. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. and D are too late to provide antibody protection. When the client is dehydrated. Checking for firmness of the uterus can be done. she should take the missed pills but use another method of birth control for the remainder of the cycle. Infants of mothers who smoke are often low in birth weight. if she misses more than two. Answers B. not hyperglycemic. Answer A is correct. Answer A is correct. so answer A is incorrect. 121. but the first action should be to check the fetal heart tones. another method of birth control should be used. and answer D is often present before menses or with the use of oral contraceptives. If the client misses a birth control pill. hypertension. If she misses two. . The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The answers in B. Growth retardation is associated with smoking. Often these clients have lighter menses. Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The signs in answers A. she will have metabolic acidosis. 124. 118. she should take two. The infant of a diabetic mother is usually large for gestational age. A detailed history can be done later. Answer D is incorrect because the client will not be in alkalosis with persistent vomiting. answer D is incorrect. Answer B is correct. and D— those with diabetes. Answer B is incorrect because the infant will not be hyperglycemic. Answers A and C are incorrect because they are respiratory dehydration. With vomiting comes dehydration. Answer D is correct. Answer C is incorrect. To provide protection against antibody production. C. C. Approximately 5–10 pounds of weight gain is not unusual. she should be instructed to take the pill as soon as she remembers the pill. Answer B is correct. Infants who are large for gestational age are associated with diabetic mothers. C. 123. Answer B is correct. and thyroid disease—can be allowed to breastfeed. RhoGam can also be given during pregnancy. making answer C incorrect. so answer B is incorrect. Answers A and C may be related to a hydatidiform mole. C. Answer C is a vague answer and can be related to a urinary tract infection. but this does not affect the infant length. and will be hypoglycemic. Answer A is incorrect because the infant will not be small for gestational age. Antibiotics decrease the effectiveness of oral contraceptives. Answer B is correct. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time. Answer A is correct. The heart tones should return to baseline quickly. so answer D is incorrect. The client with a hip fracture will most likely have disalignment. 130. Body types that frequently experience osteoporosis are thin Caucasian females. The infant of an addicted mother will undergo withdrawal. nor does C. When the membranes rupture. Therefore. Following epidural anesthesia. 135. Answer B is correct. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. B. vital signs. Answer A is correct. Any alteration in fetal heart tones. The client can be checked for cervical dilation later after she is stable. After menopause. the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. there is often a transient drop in the fetal heart tones. as in answer C. but they are not most likely related to osteoporosis. 133. The active phase of labor occurs when the client is dilated 4– 7cm. answers C and D are incorrect. Bleeding is a common complication of orthopedic surgery. Answer B is correct. and D are incorrect. so answers A and C are incorrect. Answer D is incorrect because Bryant’s traction is a skin traction. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. The best way to prevent post-operative wound infection is hand washing. and D incorrect. 131. such as bradycardia or tachycardia. 128. C. Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes. Kirschner wires are used to stabilize small bones such as fingers and toes. Answer B is correct. Balanced skeletal traction uses pins and screws. and level of discomfort. Answer A is correct. Answers A. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections. not a skeletal traction. The blood-collection device should be checked frequently to ensure that the client is not . 129. the nurse should evaluate the cervical dilation. therefore. Answer B is correct. Answer B is correct. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. women lack hormones necessary to absorb and utilize calcium. Answer B is incorrect because only the affected leg is in traction. Answer D is incorrect because this type of traction is not used for fractured hips. The latent or early phase of labor is from 1cm to 3cm in dilation. C. and D are incorrect because all fractures cause pain. so answers B and D are incorrect. should be reported. not prevent infections. making answer A incorrect. After the fetal heart tones are assessed. and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.126. answers A. 132. Placing the infant in an infant seat in answer C is incorrect because this will also cause movement that can increase muscle irritability. Fetal heart tones should be assessed after the blood pressure is checked. The transition phase of labor is 8–10cm in dilation. 127. so answers A and D are incorrect. Use of prescribed antibiotics will treat infection. The infant’s hips should be off the bed approximately 15° in Bryant’s traction. making answer C incorrect. Answer C is correct. making answers A. 134. Answer A is incorrect because this does not indicate that the traction is working correctly. hemorrhaging. The client’s pain should be assessed, but this is not life-threatening. When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used; thus, answers B, C, and D are incorrect. 136. Answer A is correct. The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers B and C are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer D is incorrect. 137. Answer C is correct. The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is also not uncommon and no need for concern; therefore answers A, B, and D are incorrect. 138. Answer B is correct. Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Answer A is incorrect because simply traveling out of the country does not increase the risk. In answer C, the house was built after the lead was removed with the paint. Answer D is unrelated to the stem. 139. Answer A is correct. The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but not daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management and an abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis; therefore, answers B, C, and D are incorrect. 140. Answer B is correct. Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardioresuscitation, so answers A, C, and D are incorrect. 141. Answer B is correct. The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed, the 6-year-old with osteomylitis is infected, and the client in answer A is too old and is female; therefore, answers A, C, and D are incorrect. 142. Answer B is correct. Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect, so answers A, C, and D are incorrect. 143. Answer D is correct. A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. The cast should be handled with the palms, not the fingertips, so answer A is incorrect. Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast, making answer B incorrect. The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying; thus, answer C is incorrect. 144. Answer A is correct. There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers B, C, and D are incorrect. 145. Answer A is correct. The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required; therefore, answers B, C, and D are incorrect. 146. Answer A is correct. A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic illeus. Checking the blood pressure is a treatment for any client, offering pain medication is not called for, and checking for swelling isn’t specific to the stem, so answers B, C, and D are incorrect. 147. Answer C is correct. Halo traction will be ordered for the client with a cervical fracture. Russell’s traction is used for bones of the lower extremities, as is Buck’s traction. Cruchfield tongs are used while in the hospital and the client is immobile; therefore, answers A, B, and D are incorrect. 148. Answer B is correct. The controller for the continuous passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. The client is in the bed during CPM therapy, so answer A is incorrect. Answer C is incorrect because clients will experience pain with the treatment. Use of the CPM does not alleviate the need for physical therapy, as suggested in answer D. 149. Answer A is correct. The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Answer B is incorrect because 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. The client should walk to the middle of the walker, not to the front of the walker, making answer C incorrect. The client should be taught not to carry the walker because this would not provide stability; thus, answer D is incorrect. 150. Answer C is correct. The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze. 151. Answer B is correct. Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answers A and C are incorrect. Answer D is true, but this is not the primary rationale for performing chest tube insertion. 152. Answer D is correct. Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect. 153. Answer C is correct. Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, making answers A, B, and D incorrect. 154. Answer C is correct. Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end, as stated in D. 155. Answer B is correct. The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are incorrect. 156. Answer D is correct. Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them; therefore, answers A, B, and C are incorrect. 157. Answer A is correct. A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Obtaining a diet history should be done later, and administering an analgesic is not indicated because there is no data in the stem to indicate pain. Therefore, answers B and C are incorrect. Assessing the fetal heart tones is important, but this is not the highest priority in this situation as stated in answer D. 158. Answer A is correct. The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. Answers B, C, and D are incorrect because the client is not at higher risk for respiratory distress syndrome or pathological jaundice, and Turner’s syndrome is a genetic disorder. 159. Answer C is correct. The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, answers A, B, and D are incorrect. Pardel was used at one time to dry breast milk. 160. Answer A is correct. The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Answers B, C, and D are incorrect. There is no need to stop the infusion at this time or slow the rate. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity. 161. Answer C is correct. Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Answer A is incorrect because, to have an affected newborn, the parents must be carriers. Answer B is incorrect because both parents must be carriers. Answer D is incorrect because the parents might have affected children. Answer D is correct. Blood transfusions are usually not required. but not to the point of pain. The client may ambulate. and D are incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal. so answer B is incorrect. an enema is not needed. This makes it more difficult to regulate thyroid medication. Transition is the time during labor when the client loses concentration due to intense contractions. not the ventral side. not decreased. C. Alternating hot and cold is not necessary. Answer C is correct. Clients with rheumatoid arthritis should exercise. Answer C is incorrect because the thyroid function does not slow.162. Answer B is correct. Before ultrasonography. and pain relief. 163. Answer C is correct. Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. and D are incorrect. so answers B and C are incorrect. thus. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix. A nonstress test is done to evaluate periodic movement of the fetus. answers B. making answers A and B incorrect. The test is not mandatory. 171. and the mother’s age has no bearing on the need for the test. and D are incorrect. as stated in answer A. the client should be taught to drink plenty of fluids and not void. Answer A is incorrect because hypospadia does not concern the urethral opening. Clients with chest pain can be treated with nitroglycerin. C. This herpes virus is treated with antiviral medications. The client might have a fever before the rash appears. so answer B is incorrect. By 1 year of age. Answers A. 172. 166. Answer A is correct. 169. the infant is expected to triple his birth weight. There is no data to indicate that the client has had anesthesia or fluid volume deficit. Answer A is correct. Varicella is chicken pox. making answers C and D incorrect. Answers A. so answer D is incorrect. It does not indicate cardiovascular defects. and the client can be delivered vaginally. An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus. C. Answer D is correct. but when the rash appears. It is not done to evaluate lung maturity as in answer A. Answer B is correct. a beta blocker such as propanolol. especially because warm. 168. and there is no need to withhold food for 8 hours. moist soaks are more useful in decreasing pain. the thyroid gland triples in size. Therefore. so answer D is incorrect. C. Fetal growth is not arrested if thyroid medication is continued. Fluids are increased. 173. Clients with sickle cell crises are treated with heat. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. 170. Answer A is correct. There is no indication for an antibiotic such as Ampicillin. Answer B is correct. answers B. oxygen. Answer B is correct. Cyanosis of the feet and hands is acrocyanosis. hydration. B. or Varapamil. so answers C and D are incorrect. and C are incorrect because they are too low. 167. Anti-inflammatory drugs should be taken with meals to avoid stomach upset. 165. the temperature is usually gone. Answer B is correct. 164. and the baby should have muscle tone. . Answer C is incorrect because the size of the penis is not affected. Answer D is incorrect because the opening is on the dorsal side. An apical pulse should be 120–160. During pregnancy. so answers A. Hypospadia is a condition in which there is an opening on the dorsal side of the penis. and D are incorrect. The client is not treated with antibiotics or anticoagulants as stated in answers A and D. This is a normal finding 1 minute after birth. Answer D is correct. Wearing gloves during care will prevent transmission of the virus. not a primary alteration. 180. 176. When the client stops taking barbiturates. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed. 174. Answer A is incorrect because the hips should not be resting on the bed. If the fetal heart tones are heard in the right upper abdomen. answers A. . 178. Answer B is correct. Bryant’s traction is used for fractured femurs and dislocated hips. and C incorrect. Tachycardia is associated with stopping barbiturates. the FHTs will be located in the center of the abdomen. 177. and D are incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. Clients with shingles should be placed in contact precautions. Answer D is incorrect because the hips and legs should not be flat on the bed. the infant is most likely in the left occipital transverse position. Small meals are not a correct option for this client. Answer B is incorrect because there is the production of abnormally viscous mucus. Answer D is correct. antibiotics are not prescribed for herpes zoster. Answer B is incorrect because the client should be treated the same as other clients. Hallucinogenic drugs can cause hallucinations. but euphoria is not. Answer A is correct. and D are incorrect times to draw blood levels. A trough level should be drawn 30 minutes before the third or fourth dose. Herpes zoster is shingles. 181. diarrhea. Answer B is correct. so answer B is incorrect. This spasm can be brought on by allergies or anxiety. they do produce psychological dependence rather than physical dependence. and tachpnea. and D are incorrect. C. C. Meperidine. making answer D incorrect. the infant is in a breech presentation. 179. 175. Asthma is the presence of bronchiolar spasms. so answer D is incorrect. Barbiturates create a sedative effect. If the FHTs are heard in the left lower abdomen. therefore. The client with mania is seldom sitting long enough to eat and burns many calories for energy. making answers A. C. Answer C is incorrect because infection is not primary to asthma. Answer B is correct. B. Answer C is incorrect because the hips should not be above the level of the body. Answer A is correct. Continuous observation is ordered to prevent the client from harming himself during withdrawal. so answer C is incorrect. Covering the lesions with a sterile gauze is not necessary. it is not the priority. Answer A is incorrect even though depression and suicidal ideation go along with barbiturate use.Weight-bearing activities such as walking are useful but is not the best answer for the stem. The times in answers A. However. Answer B is correct. Answer B is correct. Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. and Cimetadine are ordered for pancreatitis. If the infant is positioned in the right occipital anterior presentation. 182. Answer A is incorrect because the primary physiological alteration is not inflammation. The hips should be elevated 15° off the bed. Answers A. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. the FHTs will be located in the right lower quadrant. Mylanta. and oxygen is not necessary for shingles. If the fetus is in the sacral position. he will experience tachycardia. If damage occurs. 193. The facial nerve is cranial nerve VII. C. and bone marrow function because this drug is toxic to the kidneys and liver." when the milk begins to be produced. apical pulse. C. thus. nor is eating a high-carbohydrate diet. The client using a diaphragm should keep the diaphragm in a cool location. Use of an incentive spirometer is not specific to clients taking Acyclovir. 185. or changes in taste. The client with chest pain should be seen first because this could indicate a myocardial infarction. answer D is incorrect. Thus. 192. and D are incorrect. Answer B is correct. not 4 hours. and C are incorrect. Limiting activity is not necessary. B. Allowing the water to run over the breast will also facilitate "letdown. Answer C is correct. answers A. the client will experience facial pain. Mothers who plan to breastfeed should drink plenty of liquids. and C are incorrect. Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. and creatinine levels are not necessary. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. It is not associated with diarrhea. answers B. therefore. The client in answer A has a blood glucose within normal limits. Pancreatic enzymes should be given with meals for optimal effects. therefore. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses. and the olfactory nerve controls smell. Answers A. 190. The lens allows light to pass through the pupil and focus light on the retina. and D are incorrect. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed. The client in answer B is maintained on blood pressure medication. Clients taking Pyridium should be taught that the medication will turn the urine orange or red. 186. answers A. and D are incorrect. assist with eye movement. Answer B is correct. Answer C is correct. 191. Answer C is correct. Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. 189. clients with a titanium hip replacement can have an MRI. Answer B is correct. The client in answer D is in no distress. Clients who are pregnant should not have an MRI because radioactive isotopes are used.183. B. C. answers A. Clients taking Amphotericin B should be monitored for liver. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery. renal. and causes bone marrow suppression. and four glasses is not enough in a 24-hour period. Answer B is correct. and D are incorrect methods of administering pancreatic enzymes. . 188. No antibiotics are used with this test and the client should remain still only when instructed. C. eye movement is controlled by the Trochear or C IV. Answer D is correct. mental confusion. Expressing milk from the breast will stimulate milk production. and nausea is a side effect. B. therefore. therefore. nor is urinary frequency. Answer A is correct. so answers A. 184. and D are incorrect. so answer B is incorrect. C. and D are incorrect. so answers C and D are not specific to this test. The auditory nerve is responsible for hearing loss and tinnitus. so answer A is incorrect. These enzymes assist the body in digesting needed nutrients. Answer D is correct. Answer A is correct. Changes in vision are not related. Calcium levels. The lens does not stimulate the retina. answers A. She should refrain from leaving the diaphragm in longer than 8 hours. making answer B incorrect. Answers A. 187. However. or magnify small objects. not a sign of toxicity. but hydrogen peroxide is drying. as stated in answer B. Neither of these drugs should be given before or after meals. Answers A. 198.. but he should stand about 5 feet from the oven while it is operating. making answers C and D incorrect. so answers A and D are incorrect. Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. 195. B. so answers B and C are incorrect. B. Methotrexate is a folic acid antagonist. B. 200. This finding is not associated with hypotension or clots. and chicken feathers is most likely allergic to the rubella vaccine. Although this is not normal. Answer C is correct. Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. making answers A. The distal end. allow 5 minutes between the two medications. or increase the number of circulating neutrophils. Answer D is correct. The client with a pacemaker should be taught to count and record his pulse rate. 205. as in answers A.m. 203. and D incorrect. and D. create a synergistic effects. Therefore. 202. answers A. or paralyze the muscles of the eye. it should be reported. They do not anesthetize the cornea. This end is on the client’s right side. Answer C is correct. Clients with color blindness will most likely have problems distinguishing violets. Answer C is correct. Answer A is correct. thus. when metabolized by the body. blues. or chest x-ray. Answer D is correct. so a snack should be offered at that time. The colors in answers A. Answer B is correct. There is no danger to the client if he has an order for a TB skin test. eggs. It is not used to treat iron-deficiency anemia.194. it is often present in clients with heart disease. and D are less commonly affected. The client does not have to avoid citrus fruits and pericare should be done. so answer A is incorrect. and D are too early in the day. When using eyedrops. 201. 199. and C are incorrect. The client with a pacemaker can use a microwave oven. NPH insulin peaks in 8–12 hours. so answer A is incorrect. and D are incorrect. If the edema is present in the hands and face. Increasing intake of meats is not associated with urinary tract infections. C. If the nurse checks the fundus and finds it to be displaced to the right or left. 197. not before meals. is on the client’s left side. Answer B is correct. but the client should eat a bedtime snack. Answer D is incorrect. Answer A is correct. Checking the blood pressure daily is not necessary for these clients. NPH insulin onsets in 90–120 minutes. Leucovorin is the drug given for toxicity to this drug. C. However. Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. answers A. and green. answer B is incorrect. The client who is allergic to neomycin is also at risk. Bacteria does not grow freely in acidic urine. The client who is allergic to dogs. Oxytoxic drugs (Pitocin) are drugs used to . Answer B is correct. is excreted with acidic urine. These medications can be used by the same client but it is not necessary to use a cyclopegic with these medications. The proximal end of the double-barrel colostomy is the end toward the small intestines. this is an indication of a full bladder. dilate the pupil. C. Cranberry juice is more alkaline and. rabbits. Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p. Answer D is correct. 204. Ankle edema is a sign of rightsided congestive heart failure. B. therefore. or 1 The times in answers B. Answer A is correct. ELISA test. and C are incorrect. 196. RhoGam is used to prevent formation of Rh antibodies. answers A. This therapy often causes the glucose levels to be elevated. and after the client delivers. thus. eliminate circulating Rh antibodies. Answer B is correct. Answer D is incorrect because displacement is associated with a full bladder. he can have an MRI. TPN is used to treat negative nitrogen balance. Clients with an internal defibrillator or a pacemaker should not have an MRI because it can cause dysrhythmias in the client with a pacemaker. or convert the Rh factor from negative to positive. answers B. The client with a protoepisiotomy will need stool softeners such as docusate sodium. Methergine is a drug used to contract the uterus. it will not lead to negative nitrogen balance. 207. a warm bath would be helpful. and D are incorrect. Strenuous exercises are not advisable. It is too early to discuss preterm labor. Answers A. Dextrose pulls fluid from the cell. The client with polio has muscle weakness. Answer A is correct. sedatives. Therefore. therefore. and D are incorrect. and D are incorrect. and D are incorrect. It has nothing to do with displacement of the uterus. Answer B is correct. Answer C is correct. Periods of rest throughout the day will conserve the client’s energy. lactated Ringer’s contains more electrolytes than the client’s serum. Visual disturbances are directly associated with polio and cannot be corrected with glasses. C. C. If the client has a need for oxygen. 206. therefore. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs. 209. will not be asleep. so the client should be assessed for allergies to iodine. but it is difficult to do so. The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. Because this is a common complication. A 6-month-old is too old for the colorful mobile. Thus. and D are incorrect. C. A hot bath can cause burns. Answer A is correct. A client with a fractured foot often has a short leg cast applied to stabilize the fracture. B. and D are incorrect. B. 210. Answer B is correct. and Parlodel is an anti-Parkinsonian drug. a discussion of future children should be instituted. . or is deaf. The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Answer B is correct. Answer C is correct. and dextrose with normal saline will also alter the intracellular fluid. Answer C is correct. so answers B. 213. so answer A is incorrect. too late to discuss whether she was using a method of birth control. Kirschner wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer. and D are incorrect. C. answers A. and D are incorrect. 215. and D are incorrect. B. C. or a signal system should be made to accommodate these problems. 211. is claustrophobic. 208. It does not provide immunity to Rh isoenzymes. and will not have a urinary catheter inserted. so answers A. insulin might be ordered. so answer C is incorrect. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. 214. so answers A. C. making answer B incorrect. Total Parenteral Nutrition is a high-glucose solution. The best toy for this age is the cars in a plastic container.contract the uterus. however. answers A. Answer C is correct. Total Parenteral Nutrition will not lead to further pancreatic disease. 212. answers A. A thyroid scan uses a dye. The client will not have a bolus of fluid. but provisions such as extension tubes for the oxygen. answer D is incorrect. Suppositories are given only with an order from the doctor. not vaginal bleeding. He is too young to play with the electronic game or the 30-piece jigsaw puzzle. Therefore. reporting urinary frequency. Answer C is correct. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation. B. Silicone oil is not injected in this client. 224. and D are incorrect. Because the nurse is unaware of when the bottle was opened or whether the saline is sterile. and D are incorrect. A Jackson-Pratt drain will not prevent the need for dressing changes. making answer B incorrect. C. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person.216. Dizziness can be associated with blood loss and is nonspecific. and D are incorrect. The client’s statement "They are trying to kill me" indicates paranoid delusions. Infants with an Apgar of 9 at 5 minutes most likely have acryocyanosis. so head lag will be present. so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. It is not unusual for the client to complain of muscles spasms with multiple fractures. B. and avoiding prolonged sitting are not necessary. thus. as stated in answer D. therefore. Immunosuppressants are used to prevent antibody formation. 221. answers A. eats. 222. not Caucasian infants. experiencing bradycardia. the diseased lens is removed. A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. antibiotics. answers B. 219. This will facilitate removal of the lens. a normal physiologic adaptation to birth. Increasing fluids. B. It does not prevent formation of blisters. the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa. answers B. Answers A. the client will have Mydriatic drops instilled to dilate the pupil. so answers A and D are incorrect. C. answers A. but this is not the primary reason for rapid rewarming. 223. Answer B is correct. Antivirals. B. Miotics constrict the pupil and are not used in cataract clients. Iridium seeds can be expelled during urination. C. and D are incorrect. making answer C incorrect. A laser is not used to smooth and reshape the lens. Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. Therefore. and D are not safe practices. answers A. 218. Answer A is correct. Answer C is correct. the cheesy appearing covering found on most full-term infants. B. Answer A is correct. Answer A is correct. Placing simple signs that indicate the location of rooms where the client sleeps. and D are incorrect. 225. The infant who is 32 weeks gestation will not be able to control his head. and D are incorrect. so answer B is incorrect. It is not related to the infant being cold. so answers A. A t-tube is used to keep the common bile duct open. reduce edema of the incision. There is no data to indicate that the client is hearing voices or is intoxicated. or being lethargic. therefore. Answer C is correct. and bathes will help the client be more independent. and D are incorrect. Answer C is correct. so answers A. Answer C is correct. It does promote movement. 220. Answer C is correct. and analgesics are not used to prevent antibody production. is also common in the client with multiple traumas. and alternating healthcare workers confuses the client. Answer A is correct. 217. 226. Nausea. Mongolian spots are common in African American infants. thus. or keep the common bile duct open. It might increase pain for a short . Before cataract removal. it is safest to obtain a new bottle. Rapid continuous rewarming of a frostbite primarily lessens cellular damage. the jejunum. Answer D is correct. Pain related to phantom limb syndrome is due to peripheral nervous system interruption. so answers A and B are incorrect. The client who is having a central venous catheter removed should be told to hold his breath and bear down. 231. and salt and ketchup are allowed. a gown. 230. answers B. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation. and a mask should be used when caring for the client and hand washing is very important. Eating more fruits and vegetables is not necessary. B. It is cultured from the nasal passages of the client. . 229. Answer B is correct. and D are incorrect. so answers A. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. so answers A. Answer B is correct. Using oils and cream-based soaps is allowed. and D are incorrect. Answer B is correct. Answer A is correct. therefore. The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. as in answer C. Answer B is incorrect because the proximal third of the small intestine is not removed. 233. Answer C is incorrect because it is not psychological. Coumadin is an anticoagulant. C. The door should remain closed. Answer B is correct. there is no correlation to the use of phenytoin and streptokinase. 228. Answer D is correct. therefore. and D are incorrect. 232. and dark-green vegetables contain vitamin K. This prevents air from entering the line. which increases clotting. and a portion of the stomach are removed and reanastomosed. This test should be done monthly. Answer C is correct. Answer A is correct. 235. 236. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH. It is also not due to infections. Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. therefore. so the client should be instructed to cover his nose and mouth when he sneezes or coughs. Drinking more liquids and avoiding crowds is not necessary. Answer A is incorrect because phantom limb pain can last several months or indefinitely. which is a part of the stomach. as is eating salt and using an electric razor. Answers B. It is not necessary for the client to wear the mask at all times. The entire stomach is not removed. Answers A. and a history of alcohol abuse is also not a factor in the order for streptokinase. 234. Answer A is correct. so answer B is incorrect. and D will not facilitate removal. One of the tests for bleeding time is a Protime. but a negative-pressure room is not necessary. as stated in answer D. C. and D are incorrect. answers A. The client with MRSA should be placed in isolation. so answers C and D are incorrect. During a Whipple procedure the head of the pancreas. the esophagus is not removed. C. and C are incorrect. 227. and D are incorrect because fruits should be cooked or washed and peeled. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. C.period of time as the feeling comes back into the extremity. the nurse should wear the mask. C. B. so answer C is incorrect. There is no reason to assess the client for allergies to pineapples or bananas. Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. answers A. Pepper is not processed and contains bacteria. and in answer D. Gloves. so answer A is incorrect. It does not determine lung maturity. Answer A is correct. so answer A is incorrect. Answer C is correct. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Answer B is correct. Answer A is correct. and slowing the intravenous infusion is not correct. The answers in A. Answer B is correct. making answers A. and atropine will speed the heart rate and are not used in this client. 247. thus. the nurse should turn off the Pitocin. The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. answers B and C are incorrect. making answer A incorrect. The infant with tetrology of falot has five heart defects. and placing the client in a semi-Fowler’s position is not appropriate for this situation. C. The Tail of Spence is located in the upper outer quadrant of the breast. Asking the doctor to suture the tracheotomy in place is not appropriate. Valium is not given in the same syringe with other medications. making answers A and C incorrect. and D are incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable. the one who should be assigned to the care of the nursing assistant is the client with dementia. Valium is an antianxiety medication. Lovenox injections should be given in the abdomen. The graph indicates ventricular tachycardia. 239. 242. 243. Only an RN or the physician can place the client in seclusion. The correct answer is marked by an X in the diagram. Answer C is correct. 240. Answer D is correct. Answer B is correct. it is not necessary to wait to inject the second medication. Therefore. Epinephrine. C. making answer B . If Pitocin is infusing. 238. He will be susceptible to bacterial infection. Performing a vaginal exam should be done after turning off the Pitocin. and D incorrect. not in the deltoid muscle. Answer A does nothing to help the client. In answer C. Voiding every 3 hours prevents stagnant urine from collecting in the bladder. Douching is not recommended and obtaining a urinalysis monthly is not necessary. C. C. The monitor indicates variable decelerations caused by cord compression. 244. Having a helper is good. Answer B is correct. and Phenergan is used as an antiemetic. but he will be no more susceptible to viral infections than other children. so answer D is incorrect. therefore. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated. answers B. The toddler with a ventricular septal defect will tire easily. A nonstress test determines periodic movement of the fetus. answers B and D are incorrect. answers B. B. or measure neurological wellbeing. so answer D is incorrect. show contractions. 245. aminophyline. Of these clients. therefore. 241. answers A. He will not grow normally but will not need more calories. and D are incorrect. The client should not aspirate after the injection or clear the air from the syringe before injection. 248. He will be treated with digoxin to slow and strengthen the heart. Therefore. Answer C is correct. The output of 300mL is indicative of hemorrhage and should be reported immediately. but the helper might not prevent the client from coughing out the tracheotomy. and D are incorrect. and D are not noted on the ECG strip. where bacteria can grow. The client should practice wiping from front to back after voiding and bowel movements. Answer A is correct.237. 246. Milking the tube is done only with an order and will not help in this situation. These medications can be given to the same client. Histoplasmosis is a fungus carried by birds. 249. Answer D is correct. dogs. A padded tongue blade is used for seizures and not for the client with tracheal edema.incorrect. so answer B is incorrect. Answer A is correct. answers A. and C are incorrect. Therefore. A nurse or physical therapist should ambulate the client with a fractured hip. or turtles. B. so answers C and D are incorrect. If the client experiences tracheal edema. . It is not transmitted to humans by cats. so answer D is incorrect. 250. the endotracheal tube or airway will not correct the problem. The client who has recently had a thyroidectomy is at risk for tracheal edema.