NURS MISCNCLEX Exam 2_Study Guide,100% CORRECT

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NURS MISCNCLEX Exam 2_Study Guide NCLEX Exam 2 Cardiac A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac c... atheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? Metformin A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? Acute Kidney Injury The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? Continue to monitor A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? Check the client's status and lead placement. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? Status of airway The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? Sinus tachycardia The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? The neurovascular status is normal because of increased blood flow through the leg. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A rise in blood pressure A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? Muffled or distant heart sounds The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." The nurse is providing instructions to a client with a diagnosis of hypertension regarding high- sodium items to be avoided. The nurse instructs the client to avoid consuming which item? Antacids The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? Stop smoking because it causes cutaneous blood vessel spasm The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? Elevate the legs higher than the heart The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? Myocardial infarction The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? Hypotension The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? Listening to lung sounds The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? "This is a normal finding." The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? An attempt to ignore or deny the need to make lifestyle changes A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? An arterial ulcer The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? Maintain activity level as prescribed. A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective? "It involves injecting an agent into the vein to damage the vein wall and close it off." A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? "Your health care provider needs to be contacted to report this problem." The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? "I need to adhere to my dietary restrictions." The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? Raspberry juice The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? "Where is the pain located?" The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? "I should use polyunsaturated oils in my diet." A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? "I'm going to have a ham and cheese sandwich and potato chips for lunch. The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? Glucose intolerance The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? "I don't have anyone to help me with doing heavy housework at home." The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? "I will eat enough daily fiber to prevent straining at stool." A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? Ambulates 10 feet (3 meters) farther each day The health care provider (HCP) has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? Tells the client that the procedure is painless and takes 30 to 60 minutes A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? Wear loose clothing with a shirt that buttons in front. A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places the highest priority on telling the client to report which sensation during the procedure? Chest pain A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? Weigh self on a daily basis. A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? "I probably will feel tired after the test from lying on a hard x-ray table for a few hours." A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? Oxygen saturation monitor Ear The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? A red, dull, thick, and immobile tympanic membrane A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? Tinnitus The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? Cranial nerve VII, facial nerve The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? Speak at normal tone and pitch, slowly and clearly. A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? Avoid sudden head movements. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? Speak at a normal volume. Endocrine A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? Intravenous infusion of normal saline An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. Comatose state, Deep, rapid breathing, Elevated blood glucose level The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. Shakiness, Palpitations, Lightheadedness A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? Convey empathy, trust, and respect toward the client. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short- acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? IV fluids containing dextrose The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? Polyuria The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? Inadequate fluid volume The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? "I need to stop my insulin." The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? Test the drainage for glucose. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. Initiate an infusion of 3% NaCl Restrict fluids to 800 mL over 24 hours Administer a vasopressin antagonist as prescribed A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? Maintain a patent airway. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? Administer short-duration insulin intravenously. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? "The best time for me to exercise is after breakfast." The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. Polyuria, Headache, Nervousness The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? "I should limit my fluids to 1 liter per day." A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional healthcare team focus on? Select all that apply. Hypotension, Hyperkalemia The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply Tremors, irritability, nervousness The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? A heart rate that is 90 beats/minute and irregular The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. Leukocytosis urinary output of 800mL/hr Clear drainage on nasal dripper pad The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? Temperature The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. Feeling cold, Loss of body hair, Persistent lethargy, Puffiness of the face A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? Respiratory distress A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. Fever, Nausea, Tremors, Confusion The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Instruct the client about thyroid replacement therapy Encourage the client to consume fluids and high-fiber foods in the diet Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? "Usually these physical changes slowly improve following treatment." The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? To treat hypocalcemic tetany A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? Take a blood glucose test before exercising. The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. A thyroid-releasing inhibitor will be prescribed, Encourage the client to consume a well- balanced diet. A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? The client needs immediate education before discharge A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? "Let me go over the types of insulins with you again." A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? Glucagon A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? Regular insulin via the intravenous (IV) route The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? Positive Trousseau's sign The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication should be included on the list? Increased thirst The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence? Increased production of glucose The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? Severe abdominal pain Eye The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? Eye medications will need to be administered for life. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? A sense of a curtain falling across the field of vision The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? Blurred vision The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. Avoid activities that require bending over, Take acetaminophen for minor eye discomfort, Place an eye shield on the surgical eye at bedtime, contact the surgeon if a decrease in visual acuity occurs Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? Note the time of day the test was done A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? Instruct the client that he or she may need glasses when driving A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? Cardiovascular disease A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? Placing an eye patch over the client's affected eye The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? Client report of tunnel vision The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? "The hearing aid should not be worn if an ear infection is present." The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. Position the client with the affected side down after the irrigation, Warm the irrigating solution to a temperature that is close to body temperature, Position the client to turn the head so that the ear to be irrigated is facing upward, Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? Speak in a normal tone and face the client when speaking. A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? Instillation of mineral oil The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? "It's a sensorineural hearing loss that occurs with the aging process." The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? Avoid air travel. The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? A myringotomy The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? Safety measures The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? Monitor for signs of facial nerve injury The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? Tinnitus The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question? Ambulation four times daily Gastrointestinal The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? Notify the health care provider (HCP). A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. Gray-blue color at the flank, Abdominal guarding and tenderness, Left upper quadrant pain with radiation to the back The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. Fever, Complaints of indigestion, Pain in the upper right quadrant after a fatty meal A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? Increase intake of fluids, including juices. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assess 8 ment finding? Malaise A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. Administer stool softeners as prescribed., Encourage a high-fiber diet to promote bowel movements without straining., Apply cold packs to the anal-rectal area over the dressing until the packing is removed. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. Coffee, Chocolate, Peppermint, Fried chicken A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? Assessing for the return of the gag reflex The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? "I'm glad I don't have to lie still for this procedure.” The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? "I ate shellfish about 2 weeks ago at a local restaurant.” The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. Nuts, Liver, Lentils The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? Document the findings. Expected drainage will range from 500 to 1000 mL/day. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A rigid, boardlike abdomen The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? Irrigating the nasogastric tube The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? Limit the fluids taken with meals. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. Maintain NPO (nothing by mouth) status, Encourage coughing and deep breathing., Give hydromorphone intravenously as prescribed for pain. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? "I should increase the fiber in my diet.” The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? Ask the client to extend the arms.-Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? Pasta with sauce The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? Pain relieved by food intake A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? Lying recumbent following meals The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? Purple discoloration of the stoma A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? This is a normal, expected event. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? Fluid and electrolyte imbalance The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? "I need to limit my intake of dietary fiber.” The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? Sweating and pallor A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? Assessment of vital signs The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? Inability to pass flatus The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? Dark red drainage A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? "I can go back to work right away.” -Rest is especially important until laboratory studies show that liver function has returned to normal. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? Leukocytosis with a shift to the left After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? Waves of loud gurgles auscultated in all 4 quadrants -Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? Pernicious anemia A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? "I eat at least 3 large meals each day.” The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? Check the suction device to make sure it is working. The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? Decreased hemoglobin A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? Applesauce and a graham cracker The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. Jaundice, Clay-colored stools, Elevated bilirubin levels, Dark or tea-colored urine The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? "I need to decrease fiber in my diet." Hematological A client enters the hospital emergency department with a nosebleed. On assessment the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action? Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? Red tongue that is smooth and sore The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures? "I need to avoid situations that may lead to an infection." The nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the client? Select all that apply. Pallor, Fever, Joint swelling, Abdominal pain The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client? Initiate an intravenous (IV) line for the administration of fluids. The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia? Shortness of breath with activity The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication? "I need to increase my fluid intake." A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? Disseminated intravascular coagulopathy (DIC) The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply. Transfusions, splenectomy, corticosteroids, immunosuppressive agents The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? Decreased production of erythropoietin is causing anemia. When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about? Dietary intake of iron The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. I may continue to use an electric shaver, I will not blow my nose if I get a cold, I should use a soft-bristled toothbrush. Immune 1. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? "I should take hot baths because they are relaxing." 2. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? "I have an autoimmune disease that causes blistering in the epidermis." 3. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? Protecting the client from infection 4. A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? Ask the client if he ever sustained a bee sting in the past. 5. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? Hairdressers 6. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. -Use nonlatex gloves. -Use medications from glass ampules. -Keep a latex-safe supply cart available in the client's area. -Avoid the use of medication vials that have rubber stoppers. 7. A client presents at the health care provider's office with complaints of a bulls-eye rash on his upper leg. Which question should the nurse ask first? "Have you been camping in the last month?" 8. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? Administer corticosteroids as prescribed for inflammation. 9. A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. -Tell the client to avoid any woody, grassy areas that may contain ticks. -Instruct the client to immediately start to take the antibiotics that are prescribed. -Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 10. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? Positive punch biopsy of the cutaneous lesions 11. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. -Record site, date, and time of the test. -Give the client a list of potential allergens if identified. 12. The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? Bananas 13. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? Ensure that the client uses an electric razor for shaving. 14. The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? Fever, hypertension, and graft tenderness 15. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? Complete blood cell (CBC) count 16. A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? Amylase 17. A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? CD4+ cell count 18. A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? Infection caused by leukopenic effects of the medication 19. A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage? Skin rash 20. Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? Cardiac conduction deficits 21. The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? Complaints of joint pain 22. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action? Tell the client to return to the clinic in 4 to 6 weeks. 23. A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? A 14 to 21 day course of doxycycline 24. The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? Facial rash 25. A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? A Western blot will be done to confirm these findings. 26. The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? Cough 27. A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? The client has disseminated histoplasmosis infection. 28. The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. -Keep liquids at the bedside. -Place a towel over the pillowcase. -Make sure the pillow has a plastic cover. -Keep a change of bed linens nearby in case they are needed. 29. A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? Remove dairy products and red meat from the meal. 30. The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity? The use of latex condoms Integumentary A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? "Take a shower immediately, lathering and rinsing several times.” A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? A skin infection of the dermis and underlying hypodermis The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. Thinner and decrease in number of reddish papules, Scarce amount of silvery-white scaly patches on the arms The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? Positive culture results -a viral culture of the lesion provides the definitive diagnosis A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. Lesion is highly metastatic Lesion is a nevus that has changes in color. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. A pearly papule with a central crater and a waxy border Location in the bald spot atop The head that is exposed to outdoor sunlight A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A white color to the skin, which is insensitive to touch -Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? Partial-thickness skin loss of the dermis An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 36% The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? Return of distal pulses- The escharotomy releases the tourniquet-like compression around the arm The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? Elevated hematocrit levels- the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? Urine output The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? Immobilization of the affected leg The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun Examine your body monthly for any lesions that may be suspicious. The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Multiple straight or wavy threadlike lines underneath the skin The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? "Apply a warm, damp washcloth if discomfort occurs.” The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. Reposition every 2 hours., Use a bed cradle as indicated. Apply protective pads to heels and elbows Provide perineal care every 8 hours and after incontinence. The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? Gastric lavage The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder? A client who tans in an indoor tanning bed The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client? "The local anesthetic may cause a stinging sensation.” The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? "I will return tomorrow to have the sutures removed.” The nurse prepares to assist the health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care? Tell the client that the procedure is painless. The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client? Keep the test sites dry. The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? Apply emollients to the skin after bathing. The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? It is caused by a tick bite. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? "This skin infection involves the deep dermis and subcutaneous fat.” The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? Applying warm compresses to the affected area The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? Clustered skin vesicles The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statements? Select all that apply. "I need to clean the site as prescribed to prevent infection.” "I need to expect some swelling and tenderness in the affected area.” The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? Apply an emollient lotion to the skin to enhance softening. Musculoskeletal The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? A sedentary 65-year-old woman who smokes cigarettes The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? I need to report a fever or swelling to my health care provider The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? Stay with the victim and encourage him or her to remain still. Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? Thick, yellow drainage from the pin sites The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? Presence of a "hot spot" on the cast A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? Impaired tissue perfusion The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? Elevated on pillows continuously for 24 to 48 hours A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? I need to avoid getting the cast wet A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? Injury to the brachial plexus nerves The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? Select all that apply. I should not use someone else's crutches I need to remove any scatter rugs at home I need to have spare crutches and tips available The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? Clear mentation The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? Numbness and tingling in the fingers A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? Separation of the wound edges The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? Rewrap the residual limb with an elastic compression bandage A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? Bending or lifting The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? Temperature of 101.6°F (38.7°C) orally The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? Uric acid level of 9.0 mg/dL (0.54 mmol/L) A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? Check the weights to ensure that they are off of the floor The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? Place a clock and calendar in the client's room The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? Signs of skin breakdown The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? The need for sensory stimulation The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? All caregivers should be told about the metal implant The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? Use a fracture pan for bowel elimination The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? The client's vital signs, muscle strength, and previous activity level The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? Within 20 to 30 minutes of application The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? Call the health care provider The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? Petal the cast edges with appropriate material Neurological 1. The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? Nail bed pressure 2. The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? Exhaling during repositioning 4. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid separates into concentric rings and tests positive for glucose. 5. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. -Keeping the linens wrinkle-free under the client – Preventing unnecessary pressure on the lower limbs – Turning and repositioning the client at least every 2 hours 6. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? Flaccid paralysis 7. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. -Loosening restrictive clothing -Removing the pillow and raising padded side rails -Positioning the client to the side, if possible, with the head flexed forward 8. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. -The client is aphasic. -The client has weakness on the right side of the body. -The client has weakness on the right side of the face and tongue. 9. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to remind him to turn his head to scan the lost visual field." 10. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? Consistently uses adaptive equipment in dressing self 11. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? Taking medications as scheduled 12. The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? "I don't need to use my walker to get to the bathroom." 13. The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? "I'll try to eat my food either very warm or very cold." 14. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? Respiratory or gastrointestinal infection during the previous month 15. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? Providing information, giving positive feedback, and encouraging relaxation 16. A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? Affect is flat, with periods of emotional lability 17. The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. -Padding the side rails of the bed -Placing an airway at the bedside -Placing oxygen and suction equipment at the bedside -Flushing the intravenous catheter to ensure that the site is patent 18. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A positive Brudzinski's sign 19. The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? "I will drive only during the daytime." 20. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? Electrocardiographic monitoring electrodes and intubation tray 21. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. -Head midline -Neck in neutral position -Head of bed elevated 30 to 45 degrees 22. The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? Notify the health care provider (HCP). 23. The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? "I need to be sure to consume foods that are low in sodium." 24. The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? Contact the health care provider (HCP). 25. A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? A hearing aid 26. The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. -Providing sensory cues -Giving simple, clear directions -Providing a stable environment -Keeping family pictures at the bedside 27. The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. -Keep suction equipment at the bedside. -Elevate the head of the bed 30 degrees. -Keep the head and neck in good alignment -Administer prescribed respiratory treatments as needed. 28. The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? Explaining equipment and procedures on an ongoing basis 29. Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? It is possible the client can hear the family. 30. The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? A neuropsychologist 31. The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? Head of bed elevated 30 to 45 degrees, head and neck midline 32. The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? Serum osmolality 280 mOsm/kg H2O (280 mmol/kg) 33. The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? Sounds will not be heard clearly unless they are loud. 34. The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? Indicates that facial puffiness will be a permanent problem 35. A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? Altered breathing pattern 36. A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? Acknowledge the client's anger and continue to encourage participation in care. 37. The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. -Provide physical aspects of care. -Prevent pushing or straining activities. -Maintain the head of the bed at 15 degrees. 38. The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? "Pain is due to stimulation of the affected nerve by pressure and temperature." 39. The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? Initiating a bowel movement every other day, 45 minutes after the largest meal of the day 40. A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? Raised toilet seat Oncology 1. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? Increased calcium level 2. The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? Encouraging fluids 3. client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? Enlarged lymph nodes 4. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? Abdominal distention 5. The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. Facial edema in the morning Serum calcium level of 12 mg/dL (3.0 mmol/L) Numbness and tingling of the lower extremities 6. A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? The development of a vesicovaginal fistula 7. The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply. Pathological fracture Urinalysis positive for nitrites Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) 8. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? Age younger than 50 years 9. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? Change the dressing as prescribed 10. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? Hematuria 11. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? "I empty the urinary collection bag when it is two-thirds full." 12. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. Radiation Chemotherapy Serum sodium level determination Medication that is antagonistic to antidiuretic hormone 13. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? Periorbital edema 14. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency? Electrocardiographic changes 15. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? "I'm going to take aspirin for my headache as soon as I get home." 16. A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. Peritonitis Hemorrhage Fistula formation Bowel perforation 17. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? Elevating the affected arm on a pillow above heart level 18. The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? Elevated on a pillow 19. The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? "I will limit sun exposure to 1 hour daily." 20. The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. Early menarche Family history of breast cancer High-dose radiation exposure to chest Previous cancer of the breast, uterus, or ovaries 21. The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions should be included in the list? Select all that apply. Obtain a MedicAlert bracelet. Prevent debris from entering the stoma. Avoid exposure to people with infections. Avoid swimming and use care when showering. 22. The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include? Personal history of ulcerative colitis or gastrointestinal polyps 23. The nurse is teaching a client who has had a laryngectomy for laryngeal cancer how to use an artificial larynx. Which statement should the nurse include in the teaching? "Hold the device alongside the neck." 24. A client has been hospitalized for removal of a cervical radiation implant used to treat cancer. The implant is removed, and the nurse provides home care instructions to the client. Which statement made by the client indicates a need for further instruction? "Foul-smelling vaginal discharge is a sign of an infection." 25. The nurse is providing instructions to the client who is receiving external radiation therapy. Which statement, if made by the client, indicates the need for further instruction? I will use a washcloth to wash the affected area." 26. The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted? The client looks at the surgical site. 27. The home health care nurse is providing instructions to a client after a vulvectomy. Which instruction should the nurse provide to the client? "Resume activities slowly, keeping in mind that walking is a beneficial activity." 28. The ambulatory care nurse is providing discharge instructions to a female client who underwent cryosurgery with laser therapy because of a positive Papanicolaou test. Which statement by the client indicates an understanding of the instructions? "I should expect the vaginal discharge to be clear and watery." 29. The nurse has provided discharge instructions to a client who underwent a right mastectomy with axillary lymph node dissection. Which statement made by the client indicates a need for further instruction regarding home care measures? "It is all right to use a straight razor to shave under my arms." 30. A client is admitted to the nursing unit after undergoing radical prostatectomy for cancer. The nurse anticipates that which problem would be of most concern to the client in the immediate postoperative period? Concern about the outcome of surgery Renal and Urinary 1. A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. Place the client on a cardiac monitor. Notify the health care provider (HCP). Review the client's medications to determine if any contain or retain potassium. 2. A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? Trauma to the bladder or abdomen 3. The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. Hemodialysis Kidney transplant Bilateral nephrectomy 4. A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? Notify the HCP before performing the catheterization. 5. The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? Palpation of a thrill over the fistula 6. A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? Dysuria and penile discharge 7. The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? Fever, nausea, vomiting, and painful scrotal edema 8. A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? Tender, indurated prostate gland that is warm to the touch 9. The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? Decreased force in the stream of urine 10. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. Check the level of the drainage bag. Reposition the client to his or her side. Place the client in good body alignment. Check the peritoneal dialysis system for kinks. 11. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? Pallor, diminished pulse, and pain in the left hand 12. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? Elevated creatinine level 13. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5°C (101.2°F). Which nursing action is most appropriate? Notify the health care provider. 14. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? Notify the health care provider (HCP). 15. A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. Insertion of a nephrostomy tube Placement of a ureteral stent with ureteroscopy 16. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? Hyperglycemia 17. A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? Increased immunosuppression therapy 18. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute 19. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? Headache, deteriorating level of consciousness, and twitching 20. The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. Nocturia Incontinence Enlarged prostate 21. The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period? Pale pink urine 22. A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further teaching when he states that he will perform which movement as part of these exercises? Bearing down as if having a bowel movement 23. A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client? Hypertension 24. The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process? Presence of family 25. The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? Red blood cell (RBC) count 26. A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. Agitation Depression Withdrawal Labile emotions 27. A client with chronic kidney disease (CKD) has been taking aluminum hydroxide gel. On the basis of this information, the nurse determines that the client is most at risk for which problem? Constipation 28. The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which problem? Anger 29. A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem? The client's white blood cell (WBC) count remains within normal limits. 30. The nurse is giving general instructions to a client receiving hemodialysis. Which statement would be most appropriate for the nurse to include? "Several types of medications should be withheld on the day of dialysis until after the procedure." Reproductive 1.A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? "Please share with me more about your concerns." 2. The community health nurse is preparing an educational class on ovarian cancer for a group of women. Which signs and symptoms should the nurse include in the presentation? Select all that apply. Having urinary urgency or frequency Experiencing pelvic or abdominal swelling 3. The nurse is interviewing a middle-aged woman with a history of fibrocystic disorder of the breasts. Which statements made by the client indicate a need for further teaching? Select all that apply. "My symptoms will decrease just before menstruation." "Taking oral contraceptives now will increase my symptoms." 4. The nursing student is asked to discuss information related to the uterus with female high school students. Which statements by the nursing student are accurate? Select all that apply. The uterus is a pelvic organ when not pregnant." "The uterus weighs approximately 2.2 pounds (1000 g) at term pregnancy." "The uterus weighs approximately 2 ounces (60 g) in the nonpregnant state." "The uterus is composed of 3 layers: endometrium, myometrium, and perimetrium." 5. A preadolescent client asks the nurse about the onset of puberty. The nurse describes which changes as indicating puberty? Select all that apply. Mood swings occur Pubic hair will develop. Breast development begins. Height will increase due to a growth spurt. 6. The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply. A blood test will confirm the diagnosis Syphilis signs and symptoms are divided into stages. Syphilis can be spread through vaginal, anal, or oral sex. 7. The nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which assessment question would assist in eliciting the most specific data regarding the cause of this syndrome? "Do you use tampons during your menstrual period?" 8. The clinic nurse has provided instructions regarding home care measures to a female client diagnosed with pelvic inflammatory disease (PID). Which statement, if made by the client, indicates an understanding of these measures? "I need to avoid tight-fitting clothing." 9. A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? "Have you had any vaginal discharge?" 10. The nurse employed in a fertility clinic is providing information to a couple considering in vitro fertilization. The nurse's explanation should most appropriately include which information? Select all that apply. A fertilized ovum is transferred into the woman's uterus. Mild spotting or cramping may occur following egg removal. A medication protocol for follicle development will be prescribed. 11. The nurse is performing an assessment on a client who asks how she might recognize when she is ovulating. The nurse should explain that which occurs at ovulation? Select all that apply. Breast tenderness Small amount of vaginal spotting Lower abdominal pain known as Mittelschmerz Presence of spinnbarkeit–thin and clear mucous discharge 12. An adolescent seen in the health care clinic has been diagnosed with endometriosis. The client asks the clinic nurse to describe this condition. Which response should the nurse provide? "It is the presence of tissue outside the uterus." 13. The nurse is providing teaching to a transgender female to male client who will be started on testosterone therapy. Which information should the nurse include in the teaching session? Select all that apply. Expect the clitoris to enlarge. Liver enzymes and cholesterol levels will need to be monitored. 14. The instructor asks a nursing student to identify the phases of the ovarian cycle. Which phases identified by the nursing student indicate an understanding of the ovarian cycle? Select all that apply. Luteal phase Follicular phase Ovulatory phase 15. A client with a history of ovarian cysts is seen by the health care provider (HCP). The client has had 2 previous surgeries related to this condition. Her HCP recommends an exploratory laparoscopic procedure for the current ovarian cyst, which has persisted for several months. The client states that the prior ovarian cysts were benign and questions the need for this procedure. Which response is best for the nurse to provide? "A prolonged ovarian abnormality should be evaluated thoroughly." 16. The client has a regular 32-day cycle. She asks on which day she most likely ovulates. How should the nurse reply? Day 18 17. A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply. "Some forms of HPV can lead to cervical cancer." "HPV is most commonly spread during vaginal or anal sexual contact." "In some types, HPV will go away on its own and does not cause health issues." 18. The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. How should the nurse respond? Select all that apply. "It is the presence of tissue outside the uterus that resembles the endometrium." Major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia." Respiratory 1. The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. Drainage system maintained below the client's chest 50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation 2. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? Check for an air leak, because the bubbling should be intermittent. 3. he nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? Perform the Valsalva maneuver. 4. The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? Flushing 5. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? Diminished breath sounds 6. The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? Promote carbon dioxide elimination. 7. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise 8. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary because family members already have been exposed Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 9. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? Bronchospasm 10. The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 10 seconds 11. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? Stop the procedure and reoxygenate the client. 12. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? Pain, especially with inspiration 13. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? Paradoxical chest movement 14. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? Increased respiratory rate 15. The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? "I should not be contagious after 2 to 3 weeks of medication therapy. 16. A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? Chest pain that occurs suddenly 17. A client who is human immunodeficiency virus (HIV)–positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? Positive 18. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? Dyspnea 19. The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? Shortness of breath 20. The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? Mask 21. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? Venturi mask 22. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? Sitting up and leaning on an overbed table 23. The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum 24. he nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? Sputum culture 25. The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. Sitting up and leaning on a table Standing and leaning against a wall Sitting up with the elbows resting on knees 26. A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? Bloody 27. The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? Deflate the cuff on the tube. 28. The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing Encouraging active range-of-motion exercises 29. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? Document the findings 30. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initialnursing action? Perform a focused respiratory assessment. 31. The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 32. The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate? Continue to monitor the client. 33. The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 34. The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? Hyperoxygenate the client. 35. The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? Suctioning the client every hour 36. The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed? The nurse places 1 finger loosely between the tie and the neck. 37. The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action? Suction the ET tube. 38. The nurse is caring for a client who is mechanically ventilated, and the high- pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. Water or a kink in the tubing Biting on the endotracheal tube Increased secretions in the airway 39. The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made? Coughing occurs with suctioning. 40. A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? Respiratory rate of 16 breaths/minute Antepartum The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. -The ductus arteriosus allows blood to bypass the fetal lungs -One vein carries oxygenated blood from the placenta to the fetus -Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? It connects the umbilical vein to the inferior vena cava A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? The appearance of the fetal external genitalia The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? Notify the health care provider (HCP) The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? It promotes the fertilized ovum's normal implantation in the top portion of the uterus The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. Allows for fetal movement Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus Can be used to measure fetal kidney function A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? Do you plan to have any other children? The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? Your type of pelvis is the most favorable for labor and birth Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. It is the way the baby gets food and oxygen It provides an exchange of nutrients and waste products between the mother and developing fetus The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? An informed consent needs to be signed before the procedure A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? The vaginal discharge may be bothersome, but is a normal occurrence A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? A normal test result The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? I need to lie flat on my back to perform the procedure The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? The client is measuring normal for gestational age The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. Ballottement Chadwick's sign Uterine enlargement Positive pregnancy test A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? Inform the client that these contractions are common and may occur throughout the pregnancy A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? July 26, 2019 The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? G = 2, T = 1, P = 0, A = 0, L = 1 The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? The client complains of a headache and blurred vision The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? I should avoid exercise because of the negative effects on insulin production The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? Evidence of bleeding, such as in the gums, petechiae, and purpura The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. Proteinuria Hypertension The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? I will need to increase my insulin dosage during the first 3 months of pregnancy A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? Isoniazid plus rifampin will be required for 9 months The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? I should drink adequate fluids and increase my intake of high-fiber foods The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. The client has a history of intravenous drug use The client has a history of sexually transmitted infections A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? I will maintain strict bed rest throughout the remainder of the pregnancy The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. Routine administration of subcutaneous heparin may be prescribed An overbed lift may be necessary if the client requires a cesarean section Thromboembolism stockings or sequential compression devices may be prescribed The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? The client has a history of cardiac disease The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? The iron is best absorbed if taken on an empty stomach A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to the chart below. History and Physical Laboratory and Diagnostic Results Medications Gravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0 Venereal Disease Research Laboratory (VDRL) nonreactive Prenatal vitamins Weight 135 lb (61 kg) Rubella immune Positive Goodell and Chadwick Rh positive, Type O You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? I will eat fresh fruits and vegetables for snacks and for dessert each day The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? Refer to Figure. Normal The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply. -Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high -The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client? This is necessary to assist in identifying potential infections that may need to be treated A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client? The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding? Fundus is at the appropriate level The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? The client has a history of hypertension During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? Diet and insulin needs change during pregnancy The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction? During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason? Reduce excessive maternal stress and fatigue The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? Whole-grain cereal The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? Leafy green vegetables A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply. The client is wearing knee-high nylon stockings The client is wearing sweatpants with snug elastic ankle bands A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction? I should do more exercises to strengthen my back muscles A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? Drink 8 glasses of water per day A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response? This test measures amniotic fluid volume and fetal activity The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem? I want to gain only 10 pounds because I want to have a small, petite baby The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? Monitor for appropriate weight gain patterns The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? Dried fruits The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item? Orange juice A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? I will need to prepare myself and my family for the loss of this pregnancy The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? History of syphilis The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? Monitoring the apical pulse The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. Use of fertility medications History of Chlamydia Use of an intrauterine device History of pelvic inflammatory disease (PID) The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? The client's last baby weighed 10 pounds at birth The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? Increased insulin The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply. Vaginal bleeding Excessive nausea and vomiting Larger-than-normal uterus for gestational age Elevated levels of human chorionic gonadotropin (hCG) The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid? Dried peas A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements? Select all that apply. -This test can be used as a screening for spina bifida -This test is a screening test, and I will need other testing if I have abnormal results -This test can indicate if I may be at an increased risk for having a child with Down syndrome A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2018, and ended the menses on March 14, 2018. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits (mmddyy). 121418 The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement? An increase in pulse rate occurs The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply. Viruses Nutrients Antibodies Medications A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms? Eating dry crackers before arising The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction? Restrict visitors who may have an active infection A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? Monitor for fetal movement A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? Reduce external stimuli A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? A private room 2 doors away from the nurses' station A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure? The procedure is performed using artificial insemination of sperm instilled through the vagina The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes? Select all that apply. Places the client at risk for dystocia Has an increased probability of cesarean section Has a flat shape that may impede fetal descent The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. Plan for weekly nonstress tests at 32 weeks Obtain nutritional counseling with a dietitian The nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid? Spinach The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? Calcium gluconate injection A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client? Pain, itching, and vaginal discharge The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd). 1116 The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness? Compression of the vena cava A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? I should wear underwear with a cotton panel liner The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and should tell the client that which change may persist after she gives birth? Striae gravidarum Intrapartum The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. - A gravida II who has just been diagnosed with dead fetus syndrome - A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The cervix is dilated completely The spontaneous urge to push is initiated from perineal pressure The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? Administer oxygen via face mask The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? Fetal heart rate of 180 beats/minute The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the –1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer. #3 is the correct answer. A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a –2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. - Increased efficiency of contractions - The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? Variable decelerations A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? Supine position with a wedge under the right hip The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? Notify the health care provider (HCP) The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? Assess the baseline fetal heart rate The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? My contractions will increase in duration and intensity Which assessment following an amniotomy should be conducted first? Fetal heart rate pattern The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? Rest between contractions The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? Discontinue the infusion of oxytocin The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? Uterine tenderness The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? Obtain equipment for a manual pelvic examination The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. Age 54 Body mass index of 28 Previous difficulty with fertility The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? Persistent nonreassuring fetal heart rate The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? Provide pain relief measures The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? Perform a vaginal examination every shift The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? Monitoring the fetal heart rate The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? The client's fear The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. Petechiae Hematuria Prolonged clotting times Oozing from injection sites The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? Forceps delivery The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? Breathe rapidly The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? Every 15 minutes The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? Palpating the maternal radial pulse while listening to the FHR The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? A fetal heart rate of 90 beats/minute The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? Continuous electronic fetal monitoring The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? Placental separation During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? Prevent dehydration and hypoxemia A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? Measure fundal height The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? Clear and maintain an open airway A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? Painless vaginal bleeding A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. Increase in fundal height Hard, boardlike abdomen Persistent abdominal pain The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? Pale straw in color, with flecks of vernix A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? Continue to monitor the client The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. Keep the room semi-dark Initiate seizure precautions Pad the side rails of the bed Avoid environmental stimulation The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? Monitoring the mother's blood pressure The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? Assess the fetal heart rate The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? Moderate variability present The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? Click on the image to indicate your answer. Image #1 is the correct answer (To assess the brachioradialis reflex, the client's thumb is held to suspend the forearm in relaxation. The nurse then strikes the forearm directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and supination of the forearm) The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? Encourage an upright or side-lying maternal position The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? Assess for signs and symptoms of labor The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? Butorphanol tartrate The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? Complaints of severe abdominal pain Newborn The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? Drying the infant with a warm blanket The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? Bring the infant to the clinic. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? Document the findings. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. -Cyanosis, -Tachypnea, -Retractions, -Audible grunts The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? Continue to breast-feed every 2 to 4 hours. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. -Irritability, -Constant crying, -Difficult to comfort The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? Abnormal palmar creases The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? Monitor the newborn's response to feedings and weight gain pattern. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. -Monitor skin temperature closely., -Reposition the newborn every 2 hours., -Cover the newborn's eyes with eye shields or patches. The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? Maintaining standard precautions at all times while caring for the newborn The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? Maintaining safety because of low blood glucose levels Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? "I will ask the nurse to attend to my infant if I am napping and my husband is not here.” The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding.” A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? "I need to breast-feed, especially for the first 6 weeks postpartum.” The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? Notify the health care provider. The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? "I need to fold the diaper above the cord to prevent infection.” The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? Select all that apply - Tremors, -Irritability, -Poor feeding The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? The mother bathes the newborn infant after a feeding.-It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation. A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? Indicates the presence of maternal infection The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? A bottle of sterile normal saline The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions.” The nurse is preparing to instruct a client on how to bathe a newborn. Which statement should the nurse include in the instruction? "Begin with the eyes and face.” The nurse is preparing to administer an injection of vitamin K to a newborn and provides the mother with information about the injection. Which information should the nurse provide? "The injection is extremely important to prevent bleeding in your baby.” The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? Make a loud, abrupt noise to startle the newborn. A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL (238 mcmol/L). The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? Assessing skin integrity and fluid status of the newborn The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100 beats per minute, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. What should be the immediate nursing intervention for this newborn? Oxygen supplementation and suctioning The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? Document the findings. The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? Administer oxygen via resuscitation bag to the newborn infant. The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only 2 vessels. How should the nurse interpret this finding? Finding 2 vessels may indicate an increased risk for other congenital anomalies. The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which findings? Select all that apply. -A copper-colored skin rash, -Mucopurulent nasal drainage (snuffles) To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement? Place a warm blanket on the examining table before placing the newborn on the table. The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine? The newborn requires some resuscitative interventions. The nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? Periodic well-baby examinations The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn. Which actions should the nurse take? Select all that apply. -Pat the baby dry gently., -Support the newborn's body during the bath., -Make sure that the room temperature is 75°F (23.9°C)., -Cleanse one body area at a time keeping other body areas covered. On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? At 1 minute after birth and 5 minutes after birth The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? 10 The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the vital signs are within normal range if which set of vital signs is noted on assessment? Heart rate 130 beats/minute, respirations 46 breaths/minute-120 to 160 beats/min, 30 to 60 breaths/minute. The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply. -A soft and flat anterior fontanel, -A triangular-shaped posterior fontanel The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider (HCP) has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? Edema resulting from bleeding below the periosteum of the cranium The nurse is admitting a newborn infant to the nursery and notes that the health care provider (HCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? Select all that apply. -Protect defect from trauma., -Maintain a thermoneutral environment., -Assess for associated birth defects such as cleft palate. Which statement, if made by the mother of a 1-day-old newborn, indicates the understanding of gastrointestinal system functioning in the infant? Select all that apply. -10 to 20 mL is the stomach capacity of a 1-day-old newborn, -90 to 150 mL is the stomach capacity of a 1-month-old infant A new mother reports that her niece was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's mother asks the nurse if her newborn also has this diagnosis. Which findings should the nurse identify as potential indicators of GER? Select all that apply. -Irritability, -Failure to thrive, -Choking with feeding, -Spitting up and regurgitation The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings should the nurse most specifically expect to note in the infant? Select all that apply. -Failure to thrive -Coughing, wheezing, and short periods of apnea An infant is born to a mother with hepatitis B. Which prophylactic measure is indicated for the infant? Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth The nurse is caring for a term newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL (2 mmol/L). Based on this information, which nursing action should be implemented? Document the finding in the electronic health record. The nurse is caring for a term newborn. Which assessment finding should alert the nurse to suspect the potential for jaundice in this infant? Presence of a cephalhematoma The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis? Stimulating for reflex responses in the extremities Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route? Phytonadione (Vitamin K) The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows Postpartum 1. A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. -Pregnancy needs to be avoided for 1 to 3 months. -The vaccine is administered by the subcutaneous route. -Exposure to immunosuppressed individuals needs to be avoided. -A hypersensitivity reaction can occur if the client has an allergy to eggs. 2. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? "You will need to bottle-feed your newborn." 3. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? "What can I do for you?" 4. The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? "We want to attend a support group." 5. The nurse evaluates the ability of a hepatitis B–positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. 6. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? Hemorrhage 7. The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action? Increase hydration by encouraging oral fluids. 8. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? Instruct the client to request help when getting out of bed. 9. The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 3 days postpartum 10. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? Client pain level 11. The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. -"I should wear a bra that provides support." -"Drinking alcohol can affect my milk supply." -"The use of caffeine can decrease my milk supply." -"I plan on having bottled water available in the refrigerator so I can get additional fluids easily." 12. The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? The diet should include additional fluids. 13. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? Massage the fundus until it is firm. 14. The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? The client with lochia that is red and has a foul-smelling odor 15. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? Notify the health care provider (HCP). 16. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? "I will begin abdominal exercises immediately." 17. After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? Support the mother in her reaction to the newborn infant. 18. The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? An increase in the pulse rate from 88 to 102 beats/minute 19. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. -Wear a supportive bra. -Rest during the acute phase. -Maintain a fluid intake of at least 3000 mL/day. -Continue to breast-feed if the breasts are not too sore. 20. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? "I should wash my nipples daily with soap and water." 21. The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? Enlarged, hardened veins 22. The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A multiparous client who delivered a large baby after oxytocin induction 23. A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? Encouraging fluid intake 24. The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? Changes in vital signs 25. The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? Prepare an ice pack for application to the area. 26. On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? Massage the fundus until it is firm. 27. On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? "Foods and fluids that will increase urine alkalinity should be consumed." 28. A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? Postpartum infection 29. Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? Blood pressure cuff 30. The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression? The mother constantly complains of tiredness and fatigue. 31. A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp. 32. A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? "Mastitis can occur at any time during breast-feeding." 33. The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? Ambulate frequently. 34. The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? Assess for hypovolemia and notify the health care provider (HCP). 35. The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal? The saturation of more than 1 peripad per hour 36. The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction? "I need to stop breast-feeding until this condition resolves." 37. After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? "The only medications I will take are prenatal vitamins and stool softeners." 38. The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? Elevation of the affected extremity 39. A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider (HCP), what is the nurse's next action? Prepare the client for surgery. 40. The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction? "I need to isolate the infant for 48 hours after beginning the antibiotics." 41. A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? Concern about the loss of the baby and personal health 42. The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? "You should not become pregnant for 2 to 3 months after administration of the vaccine." 43. The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 44. The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? The mother requests that the nurse feed the newborn because she is feeling fatigued. 45. The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs? Retained placental fragments from delivery 46. The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis? Abdominal tenderness and chills 47. Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? Encourage the client to take pain medication as prescribed. 48. The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? Palpating the uterine fundus 49. The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action? Massage the uterus until firm. 50. The postpartum unit nurse is creating a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? Encourage the mother to hold the infant when the infant cries. [Show More]

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