Exact2Pass
When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse’s response should be based on the fact that:
During burn therapy, morphine is primarily administered IV for pain management because this route:
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele’s rule is:
A client is 6 weeks pregnant. During her first prenatal visit, she asks, “How much alcohol is safe to drink during pregnancy?” The nurse’s response is:
When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?
Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?
At 16 weeks’ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, “I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?’’ The RN could suggest which one of the following?
A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, “I know that alcohol is a problem for some people, but I can stop whenever I want to. I’m never sick or miss work, and no one can complain about me.” During the initial assessment, the best response by the nurse would be:
A primigravida with a blood type A negative is at 28 weeks’ gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?
A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client’s lochia as:
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
A female client at 37 weeks’ gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:
A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?
To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife’s home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, “It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn’t a fellow allowed to forget now and then?” The client’s actions and response best demonstrate:
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother’s discharge teaching plan?
A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client’s vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4” and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, “Isn’t that a lot?” The nurse’s best response is:
A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, “I haven’t exercised in 6 days. I won’t be eating lunch today.” This statement by her most likely reflects:
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client’s best choice from the items below would be:
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
In acute episodes of mania, lithium is effective in 1–2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?
The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son’s condition by which of the following statements?
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the “tension-building phase,” the nurse might expect the client to describe which of the following?
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:
The nurse writes the following nursing diagnosis for a client in acute renal failure—Impaired gas exchange related to:
A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, “Nobody in here seems to really care about the clients. I thought nurses cared about people!” The client is exhibiting the ego defense mechanism:
Which of the following physician’s orders would the nurse question on a client with chronic arterial insufficiency?
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:
The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
The nurse is teaching a child’s parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
Which of the following lab data is representative of a client with aplastic anemia?
To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby’s mother to:
In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to:
When assessing a female child for Turner’s syndrome, the nurse observes for which of the following symptoms?
A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n):
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as “a cramp in my leg.” An appropriate nursing action is to:
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate
(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
Iron dextran (Imferon) is a parenteral iron preparation.
The nurse should know that it:
In cleansing the perineal area around the site of catheter insertion, the nurse would:
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.” The nurse should:
The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?
A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should advise him to:
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
During a client’s first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.
This may be due to:
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
Which nursing implication is appropriate for a client undergoing a paracentesis?
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client’s depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks’ gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant’s intrauterine growth retardation is:
The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client’s level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks’ gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7–8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?
A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states:
When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:
A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible. His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client’s fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus’s head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
A burn victim’s immunization history is assessed by the nurse. Which immunization is of priority concern?
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse’s primary goal is to:
A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.
The first intervention the RN should initiate is to:
A primigravida is at term. The nurse can recognize the second stage of labor by the client’s desire to:
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
A nurse is performing a vaginal exam on a client in active
labor. An important landmark to assess during labor
and delivery are the ischial spines because:
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
Which of the following should be included in discharge teaching for a client with hepatitis C?
A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks’ gestation. The nurse should be alert to which condition related to her age?
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is “rule out hepatitis.” Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?
Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, “I wish I were dead because I am worthless to everyone; I guess I am just no good.” Which response by the nurse is most appropriate at this time?