DAVID'S Q&A FOR THE NCLEX-RN EXAMINATION TEST # 2

374. A registered nurse (RN) is caring for a postpartum client who is 16 hours postdelivery. A student nurse is assisting with the care. The RN evaluates that the student needs more education about uterine assess ment when the student is observed doing which of the following?. 1. Elevating the client’s head 30 degrees before beginning the assessment. 2. Supporting the lower uterine segment during the assessment. 3. Gently palpating the uterine fundus. 4. Observing the abdomen before beginning palpation.

375.A nurse begins the assessment of a postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the uterine fundus. Which actions should the nurse take to locate the client’s fundus? Prioritize the nurse’s actions by placing each step in the correct order. ______ Place the side of one hand just above the client’s symphysis pubis ______ Press deeply into the abdomen ______ Place a hand at the level of the umbilicus ______ Massage in a circular motion ______ Position the client in supine position ______ If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage.

376. A postpartum client, who delivered a full-term infant 2 days previously, calls a nurse to her room and states that she is concerned because her breasts “seem to be growing.” She reports that the bra she wore during pregnancy is too small. She asks the nurse what is wrong with her. The nurse’s response should be based on which of the following statements?. 1. Enlarging breasts are a symptom of infection. 2. Increasing breast tissue may be a sign of postpartum fluid retention. 3. Thrombi may form in veins of the breast and cause increased breast size. 4. Breast tissue increases in the early postpartum period as milk forms.

377.While assessing a postpartum client who is 10 hours post-vaginal delivery, a nurse notes a perineal pad that is totally saturated with lochia. To determine the significance of this finding, which question should the nurse ask the client first?. 1. “Are you having uterine cramping?”. 2. “When was the last time you changed your peri pad?”. 3. “Are you having any difficulty emptying your bladder?”. 4. “Have you passed any clots?”.

378.At 0600 hours, a registered nurse (RN) assesses the fundus of a postpartum client who had a vaginal birth at 0030 and finds that it is firm. The RN then asks a certified nursing assistant (CNA) to assist the client out of bed for the first time. Blood begins to run down the client’s leg when she gets up, and the CNA immediately calls the RN back into the room. Which response by the nurse to the client’s bleeding is correct?. 1. Explain to the client that this extra bleeding can occur with initial ambulation. 2. Immediately assist the client back to bed. 3. Push the emergency call light in the room. 4. Call the health-care provider to report this increased bleeding.

379.A licensed practical nurse (LPN) asks a registered nurse (RN) to assist in assessing the location of the fundus of a client who is 8 hours post-vaginal deliv ery. Place an X on the abdomen where the RN should expect to locate the client’s fundus.

380.Which observation of a client should lead a nurse to be concerned about the client’s attachment to her male infant?. 1. Asking the licensed practical nurse (LPN) about how to change her infant’s diaper. 2. Comparing her baby’s nose to her brother’s nose. 3. Calling the baby by name. 4. Repeatedly telling her husband that she wanted a girl.

381. When caring for a postpartum family, a nurse deter mines that paternal engrossment is occurring when the newborn’s father is observed: 1. talking to his newborn from across the room. 2. discussing the similarity between his ears and the newborn’s ears. 3. expressing feelings of frustration when the infant cries. 4. being hesitant to touch his newborn.

382.While caring for a postpartum primiparous client, who is 13 hours post-vaginal delivery, a nurse ob serves that the client is passive and hesitant about making decisions concerning her own care and the care of her newborn. In response to this observation, which interventions should be implemented by the nurse? SELECT ALL THAT APPLY. 1. Question her closely about the presence of pain. 2. Ask her if she would like to talk about her birth experience. 3. Encourage her to nap when her infant is napping. 4. Encourage participation in any unit learning activities about infant care. 5. Suggest that she begin to write her birth announcements.

383.While assisting with the vaginal delivery of a full term newborn, a nurse observes that, in spite of the fact that the client did not have an episiotomy or a perineal laceration, her perineum and labia are ede matous. To promote comfort and decrease the edema, which intervention is most appropriate?. 1. Applying an ice pack to the perineum. 2. Teaching the client to relax her buttocks before sitting in a chair. 3. Applying a warm pack. 4. Providing the client with a plastic donut cushion to be used when sitting.

384.A nurse enters the room of a postpartum, multiparous client and observes the client rubbing her abdomen. The nurse asks the client if she is having pain. The client says she feels like she is having menstrual cramps. In response to this information, which inter vention should be implemented by the nurse?. 1. Offer a warm blanket for her abdomen. 2. Encourage her to lie on her stomach until the cramping stops. 3. Instruct the client to avoid ambulation while having pain. 4. Check her lochia flow, as pain can sometimes precede hemorrhage.

385.Two hours after delivery, a mother, who is bottle feeding, tells a nurse that she experienced “terrible pain when my milk came in with my last baby.” The client asks if there is a way this can be prevented from happening after this birthing experience. Which response by the nurse is most appropriate?. 1. “Once you have recovered from the birth I will help you bind your breasts.”. 2. “Development of engorgement is familial; if you had it with your last pregnancy there probably is no way to avoid it with this birth.”. 3. “You should put on a supportive bra as soon as possible and wear it continuously for the next 1 to 2 weeks.”. 4. “Engorgement usually occurs immediately after birth, so if you don’t have it yet you probably won’t develop it.”.

386. A postpartum client, who is 24 hours post cesarean section, tells a nurse that she has had much less lochial discharge after this birth than she had with her vaginal birth 2 years ago. The client asks the nurse if this is a normal response to a cesarean birth. Which statement should be the basis for the nurse’s response?. 1. A decrease in lochia is not expected after cesarean section and further assessment is needed. 2. Women usually have increased lochial discharge after cesarean births. 3. Women normally have less lochia after cesarean births. 4. The amount of lochial discharge after cesarean section is related to method of placental delivery and whether the surgery was emergent or planned.

387.In the process of preparing a client for discharge after cesarean section, a nurse addresses all of the follow ing areas during discharge education. Which should be the priority advice for the client?. 1. How to manage her incision. 2. The need to plan for assistance at home. 3. Infant care procedures. 4. Increased need for rest.

388.A postpartum client, who is 24 hours post-vaginal birth and breastfeeding, asks a nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?. 1. “Simple abdominal and pelvic exercises can begin right now.”. 2. “You will need to wait until after your 6-week postpartum checkup.”. 3. “Once your lochia has stopped you can begin exercising.”. 4. “You should not exercise while you are breastfeeding.”.

389.In the process of teaching a Muslim woman to breast feed her infant, a nurse spends time with the mother attempting to help the baby correctly latch to the breast. During the teaching session, two student nurses are observing the instruction. Later that day, the client requests that the nurse who had given the breastfeeding instructions not be allowed to continue to provide her postpartum care. What most likely caused the client to be uncomfortable with the first nurse?. 1. Muslim women do not want to breastfeed while in the hospital. 2. Muslim women prefer to wait for their milk to come in before they breastfeed. 3. Muslim women are uncomfortable breastfeeding in public situations. 4. Muslim women only breastfeed after the infant is given boiled water.

390.While evaluating a breastfeeding session, a nurse de termines that the infant has appropriately latched on to the mother’s breast when which observations are made? SELECT ALL THAT APPLY. 1. The mother reports a firm tugging feeling on her nipple. 2. A smacking sound is heard each time the baby sucks. 3. The baby’s mouth covers only the mother’s nipple. 4. The baby’s nose, mouth, and chin are all touching the breast. 5. The baby sucks with cheeks rounded. 6. Swallowing is audible.

391. A primiparous client, who is bottle feeding her infant, asks a nurse when she can expect to start having her menstrual cycle again. Which response by the nurse is most accurate?. 1. “Most women who bottle feed their infants can expect their periods to return within 6 to 10 weeks after birth.”. 2. “Your period should return a few days after your lochial discharge stops.”. 3. “You will notice a change in your vaginal discharge from pink to white; once that happens your period should return within a week.”. 4. “Bottle feeding will delay the return of a normal menstrual cycle until 6 months post-birth.”.

392.While in the hospital after the birth of her first child, a 25-year-old single client tells a nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, the nurse recog nizes that which method of birth control would be contraindicated for this client?. 1. An intrauterine device (IUD). 2. Depot-medroxyprogesterone acetate (Depo-Provera®) injections. 3. A female condom. 4. A diaphragm.

393. After delivering a full-term infant, a breastfeed ing mother, who is preparing for discharge, asks a nurse if there is any type of contraceptive method that should be avoided while she is breastfeeding. Which contraceptive should the nurse advise the client to avoid?. 1. A diaphragm. 2. An intrauterine device (IUD). 3. The combined oral contraceptive (COC) pill. 4. The progesterone-only mini pill.

394.While assessing a breastfeeding mother 24 hours postdelivery, a nurse notes that the client’s breasts are hard and painful. In response to this assessment find ing, which interventions should be implemented by the nurse? SELECT ALL THAT APPLY. 1. Instructing the mother to breastfeed the infant from both breasts at each feeding. 2. Applying ice to the breasts at intervals between feedings. 3. Giving supplemental formula at least one time in a 24-hour period. 4. Administering anti-inflammatory medication. 5. Applying warm, moist packs to the breast between feedings. 6. Pumping the breasts as needed to ensure complete emptying.

395.A client who has been diagnosed with mastitis asks a nurse if she should stop breastfeeding since she has developed a breast infection. Which response by the nurse is best?. 1. “Continuing to breastfeed will decrease the duration of the mastitis.”. 2. “Breastfeeding should only be continued if symptoms decrease.”. 3. “It is a good idea to discontinue feeding for 24 hours until antibiotic therapy begins to take effect.”. 4. “It is appropriate to discontinue breastfeeding because the infant may become infected.”.

396.Before beginning an admission interview, a nurse re views the health records of a 25-year-old postpartum client. After reading that the client is being admitted for mastitis, which interventions should the nurse an ticipate including in the client’s plan of care? SELECT ALL THAT APPLY. 1. Encouraging ambulation at least four times in 24 hours. 2. Antibiotics. 3. Local application of warm moist packs. 4. Non steroidal anti-inflammatory agents. 5. Decreasing oral fluid intake to 1,000 mL per day. 6. Frequent emptying of the breasts.

397. While assisting with the delivery of a term newborn, which intervention should a nurse antici pate to prevent postpartum hemorrhage during the third stage of labor?. 1. Administration of intravenous oxytocin (Pitocin®). 2. Application of fundal pressure. 3. Clamping the umbilical cord before pulsations stop. 4. Administration of subcutaneous terbutaline sulfate (Brethine®).

398.While working in a perinatal clinic, a nurse receives a phone call from a client who is 20 days postpartum. The client tells the nurse she has been having heavy, bright red bleeding since leaving the hospital 18 days ago. She is concerned and wonders what she should do. Which instruction to the client is correct?. 1. Come to the clinic immediately. 2. Decrease physical activity until the bleeding stops. 3. Stop being concerned because this is expected after birth. 4. Call again next week if the bleeding has not stopped by then.

399.A nurse has been given a report on a postpartum client that includes the information that the client suffered a fourth-degree perineal laceration during her vaginal birth. In response to this information, which interven tion should the nurse add to the client’s plan of care?. 1. Limit ambulation to bathroom privileges only. 2. Monitor the uterus for firmness every 2 hours. 3. Instruct the client on a high-fiber diet and administer stool softeners. 4. Decrease fluid intake to 1,000 mL every 24 hours.

400.A postpartum client, who had a forceps-assisted vagi nal birth 4 hours ago, calls a nurse to her room to re port continuing perineal pain rated at 7 out of 10 on a numeric scale and rectal pressure, even though an oral analgesic was given and ice applied to the per ineum. Considering this information, what should be the nurse’s next intervention?. 1. Call the health-care provider (HCP) to report the pain level. 2. Closely reinspect the perineum. 3. Encourage ambulation. 4. Administer a stool softener.

401.A postpartum client is being discharged to home with a streptococcal puerperal infection. The client is tak ing antibiotics but asks a nurse what precautions she should take at home to prevent spreading the infec tion to her husband, newborn, and toddler. Which is the best response by the nurse?. 1. “You should wear a mask when caring for your newborn and toddler.”. 2. “You need to perform hand hygiene before caring for your children and after toileting and perineal care.”. 3. “Your husband should provide all of the care for both children until your infection is gone.”. 4. “No precautions are necessary since you are taking antibiotics.”.

402. A student nurse is assisting a registered nurse (RN) in the care of a postpartum client who is 48 hours post–vaginal delivery. The student reports finding a warm, red, tender area on the client’s left calf. The nurse assesses the client and explains to the student that postpartum clients are at increased risk for thrombophlebitis because of which of the following? SELECT ALL THAT APPLY. 1. The fibrinogen levels in the blood are elevated. 2. Fluids normally shift from the interstitial to the intravascular space. 3. Postpartum hormonal shifts irritate vascular basement membranes. 4. The legs are elevated in stirrups at the time of delivery. 5. Dilation of the veins in the lower extremities is present. 6. Compression of the common iliac vein occurs during pregnancy.

403.A nurse enters the room of a postpartum client who delivered a healthy newborn 36 hours previously. The nurse finds the client crying. When asked what is wrong, the client replies, “Nothing really. I’m not in pain or anything but I just seem to cry a lot for no reason.” Based on this information, what should be the nurse’s first intervention?. 1. Call the client’s support person to come and sit with her. 2. Remind the client that she has a healthy baby and there is nothing to cry about. 3. Call the health-care provider (HCP) immediately and report the incidence. 4. Ask the client to discuss her birth experience.

404. As part of discharge education for a postpartum client, a nurse suggests prevention strategies for post partum depression. Which prevention strategies should the nurse include when educating the client on postpartum depression? SELECT ALL THAT APPLY. 1. Attending a postpartum support group. 2. Using the baby’s nap time to complete household chores. 3. Keeping a journal of feelings during the postpartum period. 4. Notifying the health-care provider if feelings of being overwhelmed do not subside quickly. 5. Setting a daily schedule and following it. 6. Completing major life changes within the first year after the birth.

405.The husband of a postpartum client, who has been di agnosed with postpartum depression (PPD), is con cerned and asks a nurse what kind of treatment his wife will require. The nurse’s response should be based on the knowledge that the collaborative plan of care for PPD includes which of the following?. 1. Antidepressant medications and psychotherapy. 2. Psychotherapy alone. 3. Removal of the infant from the home. 4. Hypnotic agents and psychotherapy.

406.A nurse is caring for a postpartum client who is 15 years old. The nurse has concerns about this client’s ability to parent a newborn because the nurse recognizes that developmentally the client is: 1. developing autonomy. 2. motivated to follow rules established by outside sources. 3. career oriented. 4. egocentric.

407.A nurse meets a frantic father at an emergency de partment door who says he just delivered a full-term newborn baby in the car in the hospital parking lot. It is winter and the temperature outside is only 10°F ( 12.2°C). In response to the cold environment, the nurse knows that the infant’s body will immediately begin to produce heat by: 1. shivering. 2. metabolizing brown fat. 3. dilation of surface blood vessels. 4. decreasing flexion of the extremities.

408.At a prenatal class, a nurse is discussing changes that occur in newborn circulation at birth. The nurse uti lizes a picture of the fetal heart to explain that func tional closure of the ductus arteriosus occurs within 15 hours after birth. Place an X on the fetal heart structure that the nurse would identify as the ductus arteriosus.

409.While completing an assessment on a 4-hours-old newborn, a nurse notes the following documentation in the newborn’s chart: “clamping of the umbilical cord was delayed until cord pulsations ceased.” The nurse anticipates that this delayed cord clamping will result in: 1. more rapid expulsion of meconium from the newborn intestinal tract. 2. increased newborn alertness after birth. 3. an increase in initial newborn temperature. 4. an increase in the newborn’s hemoglobin and hematocrit.

410. A nurse is completing the 1-minute Apgar as sessment on a full-term newborn. The heart rate is 80 beats per minute. In response to this assessment, the nurse should: 1. document a 2 for the heart rate parameter of the Apgar score. 2. document a 0 for the heart rate parameter of the Apgar score. 3. continue to evaluate the rest of the Apgar scoring parameters before determining a heart rate score. 4. begin immediate positive pressure ventilation.

411. A woman with oligohydraminos and suspected intrauterine growth restriction gives birth to an infant. The infant’s 1-minute Apgar score was 6, and the 5-minute Apgar score is 7. Which conclusion should the nurse make from this information?. 1. A low Apgar score at 1 minute correlates with infant mortality. 2. A 5-minute Apgar score of 7 to 10 is considered normal. 3. A 5-minute score greater than 9 indicates a decreased risk of neurological impairment. 4. Gestational age, resuscitation measures, and obstetrical medications did not affect the Apgar score.

412. A nurse knows that maintaining a newborn’s axillary body temperature between 97.7°F (36.5°C) and 98.9°F (37.2°C) is an appropriate outcome. To accomplish this outcome the nurse should: SELECT ALL THAT APPLY. 1. dry the infant immediately after birth. 2. place the infant skin-to-skin with the mother. 3. apply leggings to the infant’s legs. 4. cover the infant’s head with a stocking cap. 5. place the infant in a crib close to the delivery room wall. 6. wrap the infant in warm blankets and place him under a radiant heat source.

413.As a nurse prepares to administer prophylactic eye treatment to prevent gonorrheal conjunctivitis to a full-term newborn, the father of the newborn asks if it is really necessary to put something into his baby’s eyes. The nurse’s response is based on the knowledge that: 1. it is the law in the United States that newborns receive this treatment. 2. this treatment is recommended but may be omitted at the parent’s verbal request. 3. the antibiotic used for the treatment can be given orally at the parent’s request. 3. the antibiotic used for the treatment can be given orally at the parent’s request.

414. Immediately after assisting with the birth of a full-term infant, a nurse determines that promoting parent-infant attachment is an appropriate outcome. To accomplish this outcome, the nurse should: SELECT ALL THAT APPLY. 1. encourage the mother to take a short nap before interacting with her newborn. 2. dim the lights in the birthing room. 3. place the newly delivered infant on the mother’s abdomen. 4. delay instillation of ophthalmic antibiotic 1 hour. 5. play loud music to keep the infant stimulated. 6. encourage the parents to delay phone calls for 1 hour after birth.

415. The father of a 12-hour-old newborn calls a nurse into his wife’s hospital room. He is agitated and reports to the nurse that his baby’s hands and feet are blue. The nurse confirms acrocyanosis and intervenes by: 1. immediately stimulating the infant to cry. 2. explaining to the father that this is an expected finding in a newborn. 3. assessing the newborn’s temperature. 4. assessing the newborn’s cardiac status.

416. During the initial assessment of a full-term newborn, a nurse measures both the infant’s chest and head cir cumference. The infant’s father observes this assess ment and asks the nurse why these measurements are necessary. Which explanation by the nurse is most accurate?. 1. Comparing these measurements provides information about any head or chest growth abnormalities. 2. Measuring the head circumference provides information about future intellectual ability. 3. Measuring a newborn’s chest provides data to assist with assessment of cardiac health. 4. Comparing head and chest circumference measurements provides information about future adult body size.

417. While assessing an 8-hour-old newborn, a nurse finds an axillary temperature of 97°F (36.1°C). In response to this finding, the nurse’s first intervention should be to: 1. document the findings. 2. place the infant under a radiant warmer. 3. feed the infant warmed formula. 4. call the health-care provider to report the findings.

418. A nurse receives a call from the laboratory re porting a blood sugar of 46 mg/dL for a full-term newborn. In response to this information, the nurse should: 1. feed the infant formula. 2. immediately feed the infant water with 10% dextrose. 3. report the findings immediately to the health-care provider. 4. document the information in the newborn’s health care record.

419. During the assessment of a full-term newborn infant who is 40 hours old, a nurse evaluates the infant for jaundice by: 1. removing the diaper and assessing the color of the genitalia. 2. applying pressure on the forehead for a few seconds and evaluating the skin color after the pressure is removed. 3. assessing the color of the palms of the hands and comparing that skin color to the color of the soles of the feet. 4. assessing the color of the infant’s tongue and palate.

420.According to the date of the mother’s last menstrual period (LMP), the nurse determines that the newborn just born has a gestational age of 40 weeks. Consid ering that data, the nurse anticipates that physical as sessment of the newborn will demonstrate: SELECT ALL THAT APPLY. 1. hypertonic flexion of all extremities. 2. sole creases on the anterior two-thirds of the sole. 3. well-defined incurving of the entire ear pinna. 4. a prominent clitoris. 5. the ability to touch the infant’s heel to his or her ear in a supine position. 6. the ability of the infant to support his or her head momentarily when being pulled from a supine to a sitting position.

421. A new mother of a 2-hour-old full-term newborn calls a nurse into her room and very excitedly tells the nurse, “Something black is coming out of my baby.” The nurse examines the diaper and finds that the infant has passed meconium stool. Which response by the nurse is most appropriate?. 1. “Black stools often indicate bleeding in the gastrointestinal tract. I will notify your health-care provider immediately.”. 2. “Are you breastfeeding? If so, the stools will always have this dark color.”. 3. “All babies pass this type of stool initially.”. 4. “I’m going to check the baby’s temperature. This happens when babies need to be warmed.”.

422.While performing an initial assessment on a full-term female infant, a nurse notes the following skin discol oration. What should be the nurse’s interpretation of this finding?. 1. The infant was bruised during delivery. 2. This is a normally occurring skin variation in newborns. 3. The infant has been placed on her back inappropriately, and this has caused bruising. 4. Seepage of blood from the intestine occurred during the birth process.

423.While assessing a full-term newborn, a nurse notes molding on the infant’s head. Considering this assess ment finding, which information should the nurse expect to see on the mother’s labor and delivery documentation?. 1. Vaginal breech birth. 2. Planned cesarean section, no labor. 3. 16-hour labor. 4. Precipitous delivery after a 30-minute labor.

424.A nurse should prepare to assess the newborn’s anterior fontanel by: 1. laying the infant on his or her back. 2. stimulating the infant to cry. 3. palpating over the infant’s occipital bone. 4. placing the infant in a sitting position.

425.A nurse evaluates that a mother understands informa tion provided about her newborn’s milia when the mother says: 1. “I will put lotion on my infant’s nose twice a day.”. 2. “I understand these raised white spots will clear up without treatment.”. 3. “I realize the baby will need surgery to remove these skin lesions.”. 4. “I will apply alcohol twice a day to the lesions until they disappear.”.

426.While providing discharge education to the Native American parents of a 48-hour-old, full-term infant, a nurse recognizes the need for additional teaching about jaundice when the mother says: 1. “I know keeping my baby warm will help to decrease his jaundice.”. 2. “I know the jaundice should start to decrease after 5 days.”. 3. “The bilirubin causing the jaundice is eliminated in my baby’s stools.”. 4. “Feeding my baby frequently will help to decrease the jaundice.”.

427.In preparation to care for a primiparous client, who delivered a term newborn, a nurse reviews the client’s history and notes that the client is a lesbian, achieved her pregnancy via artificial insemination, and is in a monogamous relationship with a female partner. In response to this information, which intervention should the nurse add to the newborn’s care plan?. 1. Avoid discussion of the lesbian relationship with the client. 2. Encourage the client’s partner to participate in newborn cares. 3. Ask the partner to leave the room when the newborn is present. 4. Avoid telling the health-care staff who cares for the newborn about the client’s situation.

428. A nurse is preparing the parents of a full-term, 24-hour-old male newborn for discharge with their child. Which discharge criteria should be met before the infant leaves the hospital? SELECT ALL THAT APPLY. 1. Infant vital signs have been within normal range for the last 12 hours. 2. The infant has passed at least three meconium stools. 3. The infant has gained weight at the minimum 100 grams. 4. There has been no evidence of bleeding from the circumcision for the last 2 hours. 5. The infant has had 6 wet diapers.

429.A nurse is caring for a full-term newborn male who is 24-hours-old and was circumcised with a Gomco® clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn’s circumci sion? SELECT ALL THAT APPLY. 1. Monitoring the penis hourly for 4 to 6 hours. 2. Observing for and documenting the first voiding after circumcision. 3. Using prepackaged commercial diaper wipes for perineal cleaning to prevent infection. 4. Applying petroleum ointment around the penis after each diaper change. 5. Applying the diaper tightly to provide hemostasis. 6. Reporting penile swelling to the health-care provider.

430.A nurse admits a term newborn who is at risk to de velop neonatal abstinence syndrome (NAS) to the newborn nursery. The nurse correctly places this infant: 1. in the general nursery with 15 other infants. 2. in a small, well-lighted nursery with two other newborns. 3. alone in a small darkened nursery room. 4. right next to the charge nurse’s desk.

430.A nurse admits a term newborn who is at risk to de velop neonatal abstinence syndrome (NAS) to the newborn nursery. The nurse correctly places this infant: 1. in the general nursery with 15 other infants. 2. in a small, well-lighted nursery with two other newborns. 3. alone in a small darkened nursery room. 4. right next to the charge nurse’s desk.

431. While reviewing discharge instructions with an African couple from Kenya who are being discharged to home with their 48-hour-old, full-term newborn, a nurse discovers that the parents have not named their newborn. Which action should the nurse take in response to this information?. 1. Ask the parents to choose a name before discharge. 2. Encourage other appropriate attachment behaviors. 3. Document the finding. 4. Ask the health-care provider to delay discharge until the lack of appropriate parental attachment can be addressed.

432. During a home-care visit to the parents of a 1-week-old newborn, a nurse correctly educates the parents about continuing care of the newborn’s umbilical cord by instructing them to: 1. begin applying rubbing alcohol to the base of the cord stump three times a day. 2. attempt to gently dislodge the cord if it has not fallen off in the next week. 3. begin placing the infant in a tub of warm water that covers the cord twice a week until the cord falls off. 4. continue to place the diaper below the cord when diapering the infant.

433.A postpartum client (G2P2) is preparing for dis charge with her term newborn. She is concerned about how her 3-year-old child will react to the infant and asks a nurse for suggestions to help facilitate sib ling attachment and acceptance. Which action should the nurse suggest?. 1. Providing a doll for the older child to care for and nurture. 2. Avoiding bringing the older child to the hospital. 3. Planning for dad to care for the older child while mom provides for the newborn. 4. Encouraging the child to be “grown up,” not tolerating regression developmentally.

434.While caring for a 30-year-old, single female who de livered a term newborn, a nurse determines that the best way to assess the impact of the newborn on the client’s lifestyle would be to: 1. observe how the client interacts with her hospital visitors. 2. review the client’s prenatal record. 3. ask the client what plans she has made for newborn care at home. 4. observe the relationship between the client and her newborn’s father.

435.A new mother of a full-term newborn is concerned that her baby is not taking enough formula at each feeding. The baby weighs 7 pounds and the nurse explains that the infant needs approximately 3 ounces of fluid per pound of body weight per day. The mother then figures that her infant should be eating _______ ounces of formula every 4 hours.

436.A healthy postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother wonders if she should be giving her baby some supplemental iron also. The nurse replies:

436.A healthy postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother wonders if she should be giving her baby some supplemental iron also. The nurse replies: 1. “Your breast milk provides all the iron your baby needs.”. 2. “Once your breast milk comes in, you will need to take an iron supplement orally.”. 3. “In the next 2 weeks, your health-care practitioner will prescribe iron drops for your baby.”. 4. “If you give your baby one bottle of iron-fortified formula each day while you are breastfeeding, that will meet the infant’s iron needs.”.

437.A registered nurse (RN) is caring for a postpartum client who delivered a term newborn 24 hours previ ously. A student nurse is assisting the RN to care for this client. The nurse recognizes that the student needs more information on newborn nutrition when the nurse overhears the student telling the client that: 1. 50% of the infant’s calorie needs are met by the fat contained in the breast milk or formula. 2. lactose is the primary source of carbohydrates in breast milk and formula. 3. calcium supplementation is not needed for the newborn regardless of the feeding method. 4. supplemental water should be given to all newborns every day, regardless of feeding method.

438.While preparing parents of a 2-day-old, bottle feeding newborn for discharge, a nurse recognizes the need for additional teaching about formula feeding when one of the parents says: 1. “We will clean our baby’s bottles in the dishwasher.”. 2. “I know we can warm the formula by placing it in a bowl of warm tap water.”. 3. “If there is formula left in the bottle after the baby finishes eating I know we should put it in the refrigerator.”. 4. “We live in the city, so I know we can use our tap water to mix the powdered formula.”.

439.A breastfeeding mother is being discharged with her 2-day-old, full-term newborn. A nurse recognizes that the mother understands how to determine if her newborn is getting enough breast milk when the mother says: 1. “I know he should have at least three wet diapers tomorrow.”. 2. “I am expecting him to have one stool per day during the next week.”. 3. “I know he should weigh at least 8 ounces more than his birth weight at his 1-week checkup.”. 4. “If he nurses for 5 minutes on each breast, I know he will be getting enough milk.”.

440. A nurse is counseling an adoptive couple who is picking up their newborn from a facility. The new born has some questionable facial characteristics, and a physician has advised the adoptive parents that the infant could have fetal alcohol syndrome (FAS). What information is needed to officially diagnose a baby with FAS? SELECT ALL THAT APPLY. 1. Documented presence of abnormal facial characteristics. 2. Documented growth deficits. 3. Documented central nervous system abnormalities. 4. Documented statements of maternal alcohol consumption during pregnancy. 5. Documented maternal treatment for alcohol abuse during pregnancy.

441.A nurse is caring for a woman on an intrapartum unit who has just given birth to a baby boy. The mother is O negative. The nurse should assess for ABO incom patibility and hyperbilirubinemia if the infants blood type is: 1. O positive. 2. O negative. 3. A negative. 4. any type, because all fetuses are equally affected.

442.Before beginning a newborn physical assessment, a nurse reviews the newborn’s medical record and sees this notation: “31 weeks gestation.” Considering this information, the nurse determines that a physical as sessment of the infant should reveal: 1. flexion of all four extremities. 2. the ability to suck. 3. the absence of lanugo. 4. vernix covering the infant.

443.At the end of a shift in the neonatal intensive care unit,a nurse is calculating the total output of a preterm infant. The infant had four wet diapers dur ing the 8-hour shift. The weight of a dry diaper is 15 grams. The four wet diapers weighed 30 grams, 24 grams,21 grams,and 25 grams. The calculation of total 8-hour urine output is______mL.

444.A nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left nare. The nurse has aspirated the infant’s stomach contents, noting color,amount,and consistency,and reinserted the residual amount because it was less than a fourth of the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding. ______ Separate the barrel of the syringe from the plunger and connect the syringe barrel to the feeding tube. ______ Remove the syringe and clear the tubing with 2 to 3 mL of air. ______ Elevate the syringe 6 to 8 inches over the infant’s head. ______ Position the infant on the right side. ______ Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate. ______ Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel. ______ Cap the lavage feeding tube and tape or remove.

445. A newborn who is 33-weeks gestation and 48 hours old has been diagnosed with respiratory dis tress syndrome (RDS). A health-care provider orders the administration of surfactant via endotracheal tube. The father asks a nurse to explain how this treatment will help his baby. The nurse explains that the preterm infant is unable to produce adequate amounts of surfactant and giving it to his baby will: 1. increase PaCO2 levels in the bloodstream. 2. prevent alveoli collapse. 3. decrease PaO2 levels in the bloodstream. 4. prevent pleural effusion.

446. A nurse is caring for a preterm infant with respi ratory distress syndrome (RDS). To maximize the in fant’s respiratory status, the nurse should intervene by: 1. monitoring blood glucose levels every 4 hours. 2. cooling all inspired gases. 3. weighing the infant every other day. 4. positioning the infant in a prone position.

447.A nurse is reviewing the record of a 15-hour-old new born before beginning a physical assessment. The nurse notes the following labor history: “Mother positive for group B streptococcal (GBS) infection at 37 weeks gestation. Membranes ruptured at home 14 hours before mother presented to the hospital at 40 weeks gestation. Precipitous labor, no antibiotic given.” Considering this information, the nurse should observe the infant closely for: 1. temperature instability. 2. pink stains in the diaper. 3. meconium stools. 4. development of erythema toxicum.

448. A nurse is caring for an infant in the neonatal intensive care unit who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter, which interventions should be planned by the nurse? SELECT ALL THAT APPLY. 1. Assess the position of the catheter every shift. 2. Position the tubing close to the infant’s lower limbs. 3. Assess for erythema or discoloration of the abdominal wall. 4. Palpate for femoral, pedal, and tibial pulses every 2 to 4 hours. 5. Reposition the tubing every hour. 6. Monitor blood glucose levels.

449.While caring for a small for gestational age newborn (SGA), a nurse notes slight tremors of the extremi ties, a high-pitched cry, and an exaggerated Moro re flex. In response to these assessment findings, what should be the nurse’s first action?. 1. Assess the infant’s blood sugar level. 2. Document the findings in the infant’s medical record. 3. Immediately inform the health-care provider of the symptoms. 4. Assess the infant’s temperature.

450.A nurse is planning the care of a 2-hour-old infant at 38 weeks gestation whose mother has type 1 diabetes mellitus. The nurse writes the following NANDA di agnosis: “Altered Nutrition: less than body require ments” and appropriately adds which “related to” statement?. 1. Decreased amounts of red blood cells secondary to low erythropoietin levels. 2. Decreased amounts of total body fat secondary to decreased growth hormone. 3. Increased glucose metabolism secondary to hyperinsulinemia. 4. Increased amounts of body water.

451. While caring for a 6-hour-old, full-term newborn, a nurse notes that the newborn is showing signs of res piratory compromise. After reviewing the infant’s la bor and delivery record, the nurse suspects meconium aspiration syndrome (MAS) when which information is noted in the record?. 1. 1-hour precipitous labor, small for gestational age infant. 2. 40-hour labor, meconium-stained amniotic fluid. 3. Forceps delivery, shoulder dystocia. 4. Planned cesarean birth.

452.When assessing an infant undergoing phototherapy for hyperbilirubinema, a nurse notes a maculopapular rash over the infant’s buttocks and back. In response to this assessment finding, what action should the nurse take next?. 1. Document the results in the newborn’s medical record. 2. Call the health-care provider immediately to report this finding. 3. Discontinue the phototherapy immediately. 4. Assess the infant’s temperature.

453. The parents of a healthy 15-hour-old term new born are planning discharge from a hospital with their infant. The mother requests that the phenalketonuria (PKU) blood test be done before the infant leaves the hospital. The nurse’s response to the mother is based on the knowledge that: 1. the PKU test must be done when the infant is at least 1 month of age. 2. the parents must sign a specific consent form if the PKU screening is done before the infant is 24 hours old. 3. the PKU screening is most accurate if performed after 24 hours of life but before the infant is 7 days old. 4. the PKU test is not needed as long as the infant is tolerating feedings without diarrhea or vomiting.

454.If a nurse is concerned that a newborn may have congenital hydrocephalus, which assessment finding is noted?. 1. Bulging anterior fontanel. 2. Head circumference equal to the chest circumference. 3. A narrowed posterior fontanel. 4. Low-set ears.

455.After assisting in the delivery of a full-term infant with anencephaly, the parents ask a nurse to explain treatments that might be available for their infant. The nurse’s response is based on the knowledge that: 1. immediate surgery is necessary to repair the congenital defect. 2. anencephaly is incompatible with life, and only palliative care should be provided. 3. a shunting procedure will be necessary initially to relieve intracranial pressure. 4. antibiotics are needed initially before any treatment is started.

456.A nurse accompanies the parents of a newborn infant to the neonatal intensive care unit (NICU) to visit their newborn son who has been diagnosed with a terminal cardiac condition. The nurse understands that interventions to promote parental attachment should: 1. be delayed until it is certain that the newborn will live. 2. include encouraging the parents to provide as much care as possible for their newborn. 3. be limited to naming the baby only. 4. include reassurances that the condition is not a result of anything the mother did during her pregnancy.

457. A client presents to a walk-in travel clinic to receive vaccinations. The client tells a nurse she thinks she may be pregnant. Which vaccines, if ordered by a physician, should the nurse prepare to administer to this client?. 1. Rubella. 2. Varicella. 3. Hepatitis B. 3. Hepatitis B.

458.A pregnant woman presents to a clinic with a white, cottage-cheese like vaginal discharge, itching, and vulvar redness. A nurse should anticipate that a health-care provider will prescribe which medication?. 1. Metronidazole (Flagyl®) 250 mg twice daily for 1 week. 2. Butoconazole (Gynazole®) 2 g once. 3. Imidazole vaginal cream daily for 1 week. 4. Fluconazole (Diflucan®) 150 mg by mouth once.

459. A hospital nurse is checking charts of second trimester clients for health-care provider orders. Which order should be rewritten before the nurse can comply with the order?. 1. Aldomet (Methyldopa®) 250 mg bid by mouth for elevated blood pressure. 2. MgSO4 5 g intramuscular if BP > 160/90 mm Hg 2 readings. 3. Terbutaline (Brethine®) 5 mg q 6 hr by mouth for preterm labor. 4. Prenatal vitamins one tablet daily by mouth.

460. A nurse is caring for a 26-week-pregnant client who has been admitted twice in the past week for preterm labor. A physician orders corticosteroid ther apy as a means to assist with fetal lung maturation. The nurse should anticipate that the medication and dosage to be ordered should be: 1. methylprednisolone (Medrol®) 40 mg IM weekly until 34 weeks. 2. betamethasone (Celestone®) 12 mg IM every 24 hours for 2 doses. 3. dexamethasone (Decadron®) 6 mg IM every 12 hours for 4 doses. 4. prednisone (Deltasone®) 12 mg IM every 24 hours for 2 doses.

461.A nurse is caring for a woman who was admitted at 25.2 weeks gestation in preterm labor. The woman received nifedipine (Procardia®) but continued having contractions. The nurse is now administering magne sium sulfate (Citro-Mag®). Which assessment findings indicate that the woman is experiencing an adverse effect from the magnesium sulfate? SELECT ALL THAT APPLY. 1. Shortness of breath. 2. Nausea. 3. Hypertension. 4. Dizziness. 5. Hypotension. 6. Insomnia.

462. A nurse at an outpatient HIV Outreach Center is caring for a pregnant client diagnosed with HIV. The client is receiving highly active antiretroviral therapy (HAART). For which potential pregnancy related risk factors associated with this therapy should a nurse monitor the client? SELECT ALL THAT APPLY. 1. Preterm labor. 2. Preeclampsia. 3. Low birth weight. 4. Gestational diabetes. 5. Preeclampsia. 6. Birth defects.

463. A client, who is 8 weeks pregnant, tells a nurse that she is experiencing nausea. The client also states that she does not like to take medication and asks if there are any herbal/natural remedies that she might try. Which herb should be safe for the nurse to suggest?. 1. Ginger. 2. Milk thistle. 3. Black cohosh. 4. Echinacea.

464.A health-care provider prescribes omeprazole (Prilosec®) to a client who is 28 weeks pregnant and experiencing heartburn. A nurse educates the client about this medication and explains that it reduces heartburn by: 1. blocking the action of the enzyme that generates gastric acid. 2. blocking the H2 receptor located on the parietal cells of the stomach. 3. neutralizing the gastric acid. 4. coating the upper stomach and esophagus and decreasing the irritation from the stomach acid.

465.A nurse admits a client who is 28 weeks pregnant and experiencing congestive heart failure. When initi ating a health-care provider’s admission orders for the client, which order should the nurse question?. 1. Furosemide (Lasix®) 40 mg IV bid. 2. Captopril (Capoten®) 25 mg PO daily. 3. Digoxin (Lanoxin®) 0.125 mg IV daily. 4. Metoprolol sustained release (Toprol XL®) 50 mg PO daily.

466.A nurse is caring for a client who is diagnosed with severe preeclampsia and is receiving magnesium sul fate intraveneously (IV). When reviewing the client’s laboratory results, which value should lead the nurse to conclude that the client’s serum magnesium level is therapeutic?. 1. 2 mg/dL. 2. 10 mg/dL. 3. 6 mg/dL. 4. 0.5 mg/dL.

467. While caring for a client with severe preeclampsia who has been receiving intravenous magnesium sulfate for 24 hours, a nurse evaluates that the medication is effective when noting: 1. an increase in blood pressure. 2. an increase in urine output. 3. a decrease in platelet count. 4. an increase in hematocrit.

468.A nurse is preparing to assist with an external cephalic version on a client who is 38 weeks preg nant. As part of the preparation, the nurse administers terbutaline sulfate subcutaneously and explains to the client that this medication will: 1. decrease uterine sensation. 2. relax her uterus. 3. cause her to feel sleepy. 4. stimulate labor contractions.

469.A nurse is ordered to administer vaginal dinoprostone (Cervidil®) for cervical ripening. Place an X on the appropriate location for the medication.

470.A nurse receives orders from a health-care provider for insertion of dinoprostone (Prepidil®) for cervical ripening for four inpatient clients. For which client should the nurse question this order?. 1. Client A, who is G1P0000 and 41 weeks gestation. 2. Client B, who is a G5P4004 at 40 and 4/7 weeks gestation. 3. Client C, who is a G1P0000, type 1 diabetic at 38 weeks gestation, with evidence of fetal macrosomia. 4. Client D, who is a G2P1001 at 40 weeks gestation attempting a vaginal birth after cesarean section with the client’s other pregnancy.

471. A nurse is caring for a client receiving intravenous (IV) oxytocin (Pitocin®) for labor induction. Which manifestations would require the nurse to discontinue the IV infusion and notify the health-care provider? SELECT ALL THAT APPLY. 1. Consistent uterine resting tone of 18 mm Hg. 2. Uterine contractions occurring every 4 minutes. 3. Blood pressure increases from 100/60 to 130/85 mm Hg. 4. Urine output of 60 mL in 2 hours. 5. Fetal heart rate (FHR) of 90 beats/minute with decreased variability. 6. Increasing client discomfort during uterine contractions.

472.While adding oxytocin (Pitocin®) to a 1,000-mL bag of intravenous solution, a 30-year-old, nonpregnant, female nurse inadvertently inserts the needle into her finger, and some of the oxytocin is injected into her body. The nurse goes immediately to the agency health service to report the incident. In addition to institutional treatment for a clean needlestick, the nurse should recognize that she will need: 1. subcutaneous terbutaline to relax her uterus. 2. ibuprofen for uterine cramping. 3. no further treatment. 4. to decrease her intake of free water for the next 24 hours.

473. A nurse is caring for multiple women in labor and notes a change in fetal heart rate (FHR) patterns following medication administration. Which medica tion, if used alone, should the nurse disregard as one that has an adverse effect on FHR patterns?. 1. Magnesium sulfate. 2. Meperidine hydrochloride (Demerol®). 3. Morphine sulfate (Avinza®). 4. Betamethasone (Diprolene AF®).

474. After admitting four clients to a labor and delivery suite, for which client should a nurse anticipate the administration of zolpidem tartrate (Ambien®)?. 1. A 40-week G2P1001 client who is scheduled for a repeat cesarean section. 2. A 39-week G3P1102 client who is 5 cm dilated, 80% effaced, and having contractions every 3 minutes. 3. A 41-week G4P1112 client who is admitted for induction of labor. 4. A 40-week G1P0000 client who is 1 cm dilated, 20% effaced, and having uncomfortable poor quality uterine contractions.

475.A nurse is administering meperidine hydrochloride (Demerol®) intravenously (IV) to an actively laboring mother. The mother asks if the medication will affect her infant. Which statements should be the basis for the nurse’s response? SELECT ALL THAT APPLY. 1. Meperidine hydrochloride crosses the placenta 90 seconds after IV administration to the mother. 2. When meperidine hydrochloride is given IV, the negative fetal effects can be avoided. 3. The fetal liver takes 2 to 3 hours to activate meperidine hydrochloride. 4. Newborns whose mothers have received meperidine hydrochloride have lower Apgar scores. 5. Meperidine hydrochloride has been associated with delay in initiation of successful breastfeeding.

476. A nurse administers butorphanol tartrate (Stadol®) to a laboring client who is 6 cm dilated. After 30 min utes, the client states that she feels the urge to bear down. The nurse assesses the client and finds the client’s cervix completely dilated with the vertex at +2 station. The nurse determines delivery is imminent and is concerned that the fetus may be born during the time the butorphanol tartrate is peaking in the mother’s body. In response to this concern, which medication should the nurse prepare for administra tion to the client?. 1. Vitamin K. 2. Oxytocin (Pitocin®). 3. Naloxone (Narcan®). 4. Erythromycin.

477. A nurse is caring for a laboring client who is receiving bupivacaine (Marcaine®) per epidural route for analgesia. For which adverse effects, specific to the local anesthetic agent, should the nurse closely monitor? SELECT ALL THAT APPLY. 1. Hypotension. 2. Elevated temperature. 3. Slowing of the second stage of labor. 4. Nausea. 5. Urinary retention. 6. Sedation.

478.A laboring client, who has epidural analgesia, reports itching. A nurse informs a health-care practitioner who orders nalbuphine hydrochloride (Nubain®) 3 mg subcutaneously. The pharmacy supplies nal buphine hydrochloride as 10 mg/mL. To provide the correct dose, the nurse should plan to administer _____ mL to the client.

479. A laboring client reports back pain, and a certi fied nurse midwife (CNM) suggests that sterile water injections may decrease the pain. A nurse prepares to position the client, recognizing that the CNM will administer these injections: 1. directly into the client’s lactated Ringer’s intravenous (IV) solution. 2. into the client’s subcutaneous tissue on her abdomen. 3. intracutaneously into the client’s lower back. 4. directly into the client’s uterus.

480.A nurse is counseling a client who is 5 weeks preg nant and seeking information about pregnancy termi nation. The client asks for information about a med ical abortion using mifepristone (Mifeprex®). Which information provided by the nurse about this medica tion is most accurate? SELECT ALL THAT APPLY. 1. It must be taken immediately after the last menstrual cycle to be effective. 2. It is a progesterone antagonist and will block the action of progesterone on the uterus. 3. To be certain that the abortion occurs, the mifepristone must be followed up with a vaginal douche of vinegar and water. 4. The success rate is 96% to 98% when taken within 42 days of conception. 5. The medication must be administered intravenously (IV) in the caregiver’s office. 6. Most women will develop a transient temperature elevation when taking the medication.

481.A postpartum client, who just delivered a full-term infant, tells a nurse she is concerned about her Rh negative status. She says that she received Rho(D) immune globulin (RhoGam®) during her pregnancy, and she wonders if she is going to need it again. The nurse correctly replies: 1. “To prevent you from building up antibodies against your next baby’s blood you will need to have Rho(D) immune globulin within the next 72 hours.”. 2. “You will not need Rho(D) immune globulin again since you got it during your pregnancy.”. 3. “One dose of Rho(D) immune globulin will last for a lifetime.”. 4. “You will need Rho(D) immune globulin if your newborn is Rh positive.”.

482.A breastfeeding, postpartum client is reporting after pains. The client is requesting pain medication but does not want anything that will harm her breastfeed ing infant. A nurse anticipates that a health-care provider will order which medication?. 1. Meperidine (Demerol®). 2. Naproxen (Naprosyn®). 3. Ibuprofen (Motrin®). 4. Acetaminophen (Tylenol®).

483. A health-care provider orders that carboprost tromethamine (Hemabate®) be given to a postpartum client who is experiencing uterine atony. Because of the side effects of this medication, a nurse should also prepare to give the client: 1. a sedative. 2. a stool softener. 3. an antiemetic. 4. extra oral fluids.

484. While preparing to present women’s health in formation at a college seminar, a nurse decides to in clude information on how combination oral contra ceptives (COC) prevent conception. Which information should the nurse plan to include in the seminar? SELECT ALL THAT APPLY. 1. COCs inhibit ovulation. 2. COCs destroy the cell membrane of sperm. 3. COCs block uterine progesterone receptors. 4. COCs create an atrophic endometrium. 5. COCs promote the thickening of cervical mucous. 6. COCs have a reduced efficacy in obese individuals.

485. A nurse is caring for an infant whose mother has tested positively for hepatitis B surface antigen. The nurse is preparing to administer the hepatitis B vaccine to the infant. To prevent infection, which medication should the nurse administer along with the hepatitis B vaccine?. 1. Acyclovir (Zovirax®). 2. Ceftriaxone (Rocephin®). 3. Acetaminophen (Tylenol®). 4. Immune serum globulin (ISG).

486. Anurse in a large urban hospital is admitting a 2-hour-old infant whose mother is positive for HIV. A neonatologist orders the infant to be started on zidovu dine (Retrovir®). Which laboratory tests should the nurse analyze before administering the medication?. 1. Complete blood count (CBC) with differential, prothrombin time (PT), and bleeding time. 2. Cluster of differentiation 4 (CD4) count, CBC, and lactate. 3. CBC with differential and alanine aminotransferase (ALT). 4. CBC, CD4 count, ALT, and serum protein.

487.A nurse is preparing to administer indomethacin (Indocin®) to an infant diagnosed with patent ductus arteriosus (PDA). By which route should the nurse expect to administer the indomethacin for this infant?. 1. Intravenously (IV). 2. Orally. 3. Rectally. 4. Intramuscularly (IM).

488.A nurse is caring for a newborn infant of a diabetic mother. The infant requires intravenous (IV) D5/0.2 NS to manage blood glucose levels. When caring for the infant, which actions should be taken by the nurse? SELECT ALL THAT APPLY. 1. Assess for rebound hypoglycemia. 2. Maintain blood glucose levels between 45 mg/dL and 65 mg/dL. 3. Check blood glucose levels frequently in the first 2 to 4 days of life. 4. Titrate the IV solution rate to keep blood glucose levels within the ordered range. 5. Maintain blood glucose levels between 37 mg/dL and 40 mg/dL.

489.A nurse is caring for a newborn infant of a diabetic mother. The infant is receiving D10/0.2 NS intra venously (IV) to manage blood glucose levels. After examining the infant, a primary care provider changes the order to D12.5/0.2 NS. Which action should the nurse take first?. 1. Call pharmacy to get the newly ordered IV solution for the infant. 2. Obtain a blood glucose level prior to beginning the new infusion. 3. Contact the primary care provider to clarify the order. 4. Increase the current IV rate until the new bag is obtained from pharmacy.

490.When completing an assessment on a 6-day-old infant, a nurse identifies white, adherent patches on the tongue, palate, and inner aspect of the checks. After consult ing with a primary care provider, the nurse obtains an order for mycostatin (Nystatin®). Which is the most important information that the nurse should provide to the parent about this medication?. 1. Monitor the infant’s mouth for signs of improvement. 2. Monitor for signs of contact dermatitis. 3. Administer the medication and allow the infant to “swish and swallow.”. 4. Adverse effects of mycostatin can include nausea, vomiting, and diarrhea.

491. A nurse is caring for an infant who experienced as phyxiation at birth and is having seizure activity. The nurse has an order to administer phenobarbital 4 mg/kg/day in divided doses (q 8 hrs), with the infant weighing 4 kg. To provide the correct dose, the nurse should administer ____ mg to the infant.

492.An unsteady 20-year-old surgical client persists in ambulating to the bathroom alone despite being re minded to call for assistance. A nurse concludes that, according to Havighurst’s developmental tasks, this behavior reflects the client’s need for: 1. adjusting to physiological changes. 2. independence. 3. industry. 4. integrity.

493.A clinic nurse is planning to complete a physical examination on a 19-year-old female who has partici pated in strenuous physical activities while in high school. It would be most important for the nurse to plan to assess this client for: 1. lordosis. 2. an eating disorder. 3. an increase in muscle mass. 4. excessive bleeding with menses.

494.Place an X on the illustration that a nurse should expect to find when assessing the chest of a normal, healthy, young adult male client without chest abnormalities.

495. A nurse teaches an 18-year-old diabetic client to perform self-administration of insulin. The nurse notes that each time the client makes even a small mistake, the client constantly apologizes for getting it wrong. The nurse observes that the client also pro fusely apologizes when making a minimal mistake in other activities. The nurse concludes that, according to Erikson’s development stages, the adult may have an unresolved development task of: 1. infancy. 2. early childhood. 3. school-age childhood. 4. adolescence.

496.A nurse is collecting information from a young adult client. Which psychosocial questions should the nurse ask during the admission assessment? SELECT ALL THAT APPLY. 1. “Do you have any pets?”. 2. “How many hours of sleep do you get at night?”. 3. “When was your last bowel movement?”. 4. “How much alcohol do you consume and how frequently?”. 5. “Can you describe your sexual activity?”.

497.Which finding should a nurse expect when assessing a healthy, middle-aged adult?. 1. Weight gain of 20 pounds in the past year. 2. Tactile fremitus is absent at the apex of the lungs. 3. Able to count backward from 100 subtracting 7 each time. 4. Percussion indicates heart is larger then previous physical examination.

498.A home health nurse is caring for a middle-aged client who is disabled due to a recent motor vehicle accident. The client has few interests, spends most days watching TV, and has become estranged from the family. Which of Erikson’s developmental stages should the nurse conclude that the client is not meeting?. 1. Industry versus inferiority. 2. Initiative versus guilt. 3. Generativity versus stagnation. 4. Intimacy versus isolation.

499. A nurse is caring for a hospitalized 60-year-old Korean American client. Which statement, if made by the client, correctly reflects the Korean American culture and should alert the nurse that intervention is needed?. 1. “Since 60 is considered old age, I retired as expected. I’m now worried about insurance.”. 2. “Value is on youth and beauty; so little attention is paid to problems of the elderly.”. 3. “Fathers are expected to continue to contribute financially even for their adult children.”. 4. “Grandchildren are raised by the grandparents until school age so we have a full house.”.

500.A 50-year-old client asks a nurse how to calculate the body mass index (BMI). The client weighs 131 pounds and is 5 feet 3 inches tall. Together, the client and nurse calculate the client’s BMI to the nearest tenth. The client’s BMI is ___.

501.Which point should a nurse most specifically address when teaching a group of middle-aged female nurses about middle-aged moral development applicable only to women?. 1. Gilligan’s moral development theory includes responsibility and caring for self and others. 2. Kohlberg’s moral development theory includes living according to universally agreed upon principles. 3. Westerhoff’s stages of faith include putting faith into personal and social action and standing up for beliefs. 4. Fowler’s stages of spiritual development include becoming aware of truth from a variety of viewpoints.

502.A 62-year-old client recently retired after working 30 years as a bank manager. Which statement to a nurse during a clinic visit best suggests that the client is achieving the developmental stage of “integrity versus despair”?. 1. “Now that I have some free time, I want to treat my wife to a trip to Hawaii.”. 2. “I seem to be staying in bed longer and longer each day. There isn’t a reason to get up now.”. 3. “I am noticing the little aches and pains more; before I was just too busy to notice them.”. 4. “I get calls a few times a week for advice; my coworkers still value my suggestions.”.

503. A 60-year-old client, admitted to a hospital with chest pain, has been functioning independently at home. During the night, the client is found wandering in the hallway and states, “I can’t find my kitchen. I need a glass of milk.” The nurse’s best interpretation of the client’s behavior is: 1. the client likely had a stroke. 2. the stress of being in unfamiliar surroundings has caused the client’s confusion. 3. the decline in mental status, especially at night, is a normal part of aging. 4. this is an insidious change and it likely means the client has early dementia.

504.A nurse is caring for a 50-year-old client who reports having difficulty falling asleep. Which recommenda tions should a nurse make to this client? SELECT ALL THAT APPLY. 1. Drink a glass of wine or a beer before going to bed. 2. Avoid exercising 3 to 4 hours before bedtime. 3. Go to bed at the same time each night. 4. Use the bed for sleeping or intimacy only. 5. Eat later in the evening; people usually are sleepier after a large meal.

505.A client states to a hospice nurse, “If I could live un til my grandson’s wedding in 2 months, then I would be ready to die.” Based on this statement, the nurse should interpret that the client is in which stage of grief?. 1. Denial. 2. Depression. 3. Bargaining. 4. Acceptance.

506.A client, who is experiencing mouth soreness precipi tated by stress from completing multiple school ex aminations, visits a college health nurse. The nurse’s priority nursing diagnosis at this time should be: 1. acute pain. 2. impaired tissue integrity. 3. potential fluid volume deficit. 4. imbalanced nutrition.

507. A 32-year-old client has been trying to get pregnant for the past 10 years. The client consults a family planning clinic after being unsuccessful with the calendar and basal body temperature methods to determine the time of ovulation. Which statement by a nurse would be most appropriate?. 1. “Let me review the methods with you; maybe you have not been using them correctly.”. 2. “Have you considered that you might not be ovulating and that adoption is an option?”. 3. “Test kits are available that will detect an enzyme in cervical mucus that signals ovulation.”. 4. “If you douche or your spouse wears restrictive underwear, these can reduce your chances of conception.”.

508.A nursing unit educator is planning teaching for other nurses after noting that some nurses are unfamiliar with insulin types and how to use the new insulin injection pens. When planning teaching, which question by the educator best reflects consideration that the nurses are adult learners?. 1. “Does anyone want to volunteer to prepare a poster board?”. 2. “What specifically regarding insulin and its administration do you need to learn?”. 3. “Can you attend a presentation if I post various times during the day and evening shift?”. 4. “What don’t you understand about the information in the policy and procedure manual?”.

509. A nurse has limited time to teach an adult post operative client. The nurse should initially plan to: 1. provide brochures and handouts that the client can discuss with family members. 2. make a referral to outpatient resources for the client to receive the needed teaching. 3. establish learning needs that have the highest priority at this time and teach with each contact. 4. answer the client’s questions and leave the extensive teaching for the nurse on the next shift.

510. An 18-year-old client has a college physical completed at a clinic. No problems are evident but the client tells a nurse, “I am getting stressed worry ing about the demands of college. I am used to get ting “As and Bs.” Which statement should the nurse reserve until a follow-up visit with the client?. 1. “Expressing your feelings of anxiety to a friend or nurse helps you cope emotionally.”. 2. “I will check with the physician about prescribing paroxetine hydrochloride (Paxil®).”. 3. “Exercise increases the release of endorphins and can enhance your sense of well-being.”. 4. “If you like drawing or painting, register for an art class during your first semester in college.”.

511.A nurse is caring for a client diagnosed with hyperten sion. The nurse plans to teach the client progressive muscle relaxation to reduce stress and decrease the client’s blood pressure. Which steps should the nurse take when teaching the client to perform progressive muscle relaxation? Prioritize the nurse’s actions by placing each step in the correct order. ______ Relax the feet, imagining the tension flowing out with each exhalation. ______ Lie down in a quiet place where you are undisturbed. ______ Contract the muscles of your feet first as you inhale and hold the contraction briefly. ______ Relax your body,allowing it to feel heavy. ______ Lie still for a few minutes after the contraction and relaxation of all muscles. ______ Imagine the tension flowing out with each breath you take. ______ Move up the body,contracting then relaxing each muscle.

512.A nurse is positioning a female client in the dorsal recumbent position for a routine examination. Which picture illustrates that the nurse has correctly posi tioned this client?. 1.A. 2.B. 3.C. 4.D.

513.A hospital nurse is teaching coworkers how to pre vent varicose veins. Which recommendation by the nurse is most accurate?. 1. Wear low-heeled comfortable shoes. 2. Move your legs back and forth often. 3. Wear support hose or thromboembolic deterrent stockings (TEDS). 4. Wear clean, white cotton socks with tennis shoes.

514. A nurse evaluates that a client correctly under stands information regarding breast cancer screening when the client states: 1. “Women at average risk for breast cancer should begin having mammography at age 40.”. 2. “Women with fibrocystic breast disease should eliminate chocolate and caffeine from the diet.”. 3. “Women should perform monthly breast self examination (BSE).”. 4. “Only women with fibrocystic breast disease should have the addition of breast ultrasound or MRI.”.

515. A 25-year-old client, who had a hysterectomy due to bleeding complications from a broken intrauterine de vice (IUD), tells a nurse, “My husband will probably leave me now because I won’t be able to have any more children. I am so glad I have one child already.” Which response by the nurse is most appropriate?. 1. “That probably won’t happen. He’ll likely be thankful that you already have one child.”. 2. “Are you afraid your husband will leave you because he wants more children?”. 3. “There are support groups you and your husband could attend to help cope with your loss.”. 4. “Your husband should be thankful that you are alive and didn’t bleed to death!”.

516. A nurse assesses the coping-stress tolerance in the functional health assessment of a client diagnosed with anemia. The nurse notes that the client has a coping stress tolerance problem. Which nursing diagnoses, pertaining to the client’s coping-stress tolerance pat tern, should the nurse document in the client’s plan of care? SELECT ALL THAT APPLY. 1. Caregiver role strain. 2. Defensive coping. 3. Relocation stress syndrome. 4. Stress overload. 5. Ineffective coping. 6. Readiness for enhanced coping.

517. A health-care provider documents, in the medical record of an 87-year-old hospitalized client, normal elder skin changes of senile purpura. The elder has no other skin changes. When assessing the client, which skin change, illustrated below, should the nurse expect to find?. 1. A. 2. B. 3. C. 4. D.

518. A nurse overhears a person say: “I’m having a senior moment because I forgot....” How should the nurse interpret this statement?. 1. A comical statement without age bias. 2. A stereotypical reference to older adults that can be termed ageism. 3. Reflects age-related knowledge since memory decreases with age. 4. A derogatory remark, but one that reflects a truism.

519. When assessing the cardiovascular system of a 75-year-old male, a nurse auscultates a systolic heart murmur. This is the only abnormality noted. Which analysis by the nurse is correct?. 1. Usually representative of some kind of underlying heart disease. 2. Indication for valve replacement. 3. Indication that the client has congestive heart failure (CHF). 4. Common due to age-related calcification and stiffening of the heart valves.

520.In assessing a 75-year-old African American client, a nurse notes a blood pressure (BP) of 158/90 mm Hg. In planning care for this client, which interpretation by the nurse is correct?. 1. Blood pressure tends to increase with age, so this elevation is considered acceptable and confers no special risk. 2. This reading indicates stage 1 hypertension, so health-promoting lifestyle modifications and medications are needed. 3. This reading indicates prehypertension, so only health-promoting lifestyle modifications are needed. 4. This reading indicates stage 2 hypertension, which is treatable only with thiazide-type diuretics, regardless of diet or exercise.

521. When an office nurse completes height measurement for a 62-year-old female client, the woman says that she has lost half an inch. Which explanation by the nurse is most accurate?. 1. “As we age, we lose muscle mass.”. 2. “Bone loss is due to lack of exercise.”. 3. “Aging changes in the cartilage of the knees and hips result in shortening stature.”. 4. “The vertebral column shortens due to compression and thinning of the vertebrae with aging.”.

522.An older adult client tells a clinic nurse that her hear ing loss seems to have gotten worse in the last few days. A nurse asks if the client is experiencing any pain,has sustained any injuries,or has started taking any new medications. After performing an assess ment, the nurse concludes that the recent hearing loss may be a result of a collection of cerumen. Which age-related change contributed to the collection of cerumen?. 1.A diminution in sweat glands, longer and thicker hair growth,and thinning and drying of the skin lining the ear canal. 2.Ossicular bone calcification and longer and thicker hair growth. 3.Degenerative structural changes of the ear drum and drying of the skin lining the ear canal preventing cerumen passage. 4.Prebycusis and reduction in sweat gland activity.

523.Which interventions should a nurse implement when teaching an 86-year-old client about glaucoma and demonstrating how to administer eye drops? SELECT ALL THAT APPLY. 1.Tell the client when the teaching session to be held so that the client may ask a relative to attend if needed or preferred. 2.Provide an environment that is private,quiet,and well lit. 3.Show the client how to administer eye drops in lying,sitting,and standing positions and be detailed with the explanations to ensure understanding. 4.Engage as many of the five senses as possible during the instruction linking the information with the client’s life experience. 5.Give extensive written materials for each eye drop medication with a schedule to follow.

524.A nurse is caring for a 79-year-old client who was widowed last year and complains of being lonely. The nurse invites and encourages the client to attend local church services and activities. Which benefits are associated with participation in religious activities? SELECT ALL THAT APPLY. 1.Greater well-being and life satisfaction. 2.Higher level of participation in health promotion activities. 3.Coping mechanism for bereavement. 4.Higher levels of hope and optimism. 5.The services of a parish nurse who can provide medical care.

525.A 62-year-old female client is attending a community health fair. A health fair nurse recommends that the client make an appointment with a physician and ask that a DEXA (dual-energy x-ray absorptiometry) scan be done to evaluate for osteoporosis because the client has many risk factors. Which risk factor likely influenced the health fair nurse’s decision to recom mend a DEXA scan?. 1. Diabetes mellitus. 2. Postmenopausal. 3. Overweight. 4. African American.

526. On the first postoperative day for a 74-year-old client who had a transurethral resection of the pros trate (TURP), a nurse assists the client to ambulate several times to maintain muscle strength. The nurse’s action is based on knowing that: 1. passive exercises are not effective on aging muscles. 2. immobile gerontological clients can lose as much as 5% of muscle strength per day. 3. active exercise is the only type of exercise that aids in healing of the incision. 4. the weight-bearing exercise of walking increases deconditioning by 10%.

527. Anurse should evaluate the hydration status of an older adult client by assessing: SELECT ALL THAT APPLY. 1. urine color. 2. serum blood urea nitrogen (BUN) and creatinine. 3. serum white blood cell (WBC) and differential count. 4. urine specific gravity. 5. 24-hour fluid intake and urine output.

528.When assessing a 68-year-old client’s laboratory test results,a nurse should anticipate common age-related changes. Select the laboratory values expected to be decreased due to age-related changes. Lab Component Age-Related Change RBC WBC Platelets Hgb Hct BUN. RBC. WBC. Platelets. Hgb. Hct. BUN.

529.For which age-related skin changes should a nurse assess an 81-year-old hospitalized client to best pro tect the client from developing ducubiti?. 1.Increased tissue vascularity. 2.Increase in subcutaneous tissue. 3.Increased rate of cellular replacement. 4.Loss of skin thickness and elasticity.

530.A nurse reports to a health-care provider that a client has decreased peripheral vision. An ophthalmologist consult is ordered and the client is diagnosed with chronic open-angle glaucoma. The client cries when told the diagnosis. A nurse identifies the following nursing diagnoses. In which priority order should the nurse plan to address the nursing diagnoses?. ____ Deficient knowledge related to glaucoma causes and treatment. ____ Anxiety related to fear of vision loss and changes in quality of life. ____ Sensory/perceptual alterations (visual) related to decreased peripheral vision. ____ Dressing and grooming self-care deficit related to visual impairment.

531. An older adult client tells a clinic nurse of a fear of falling due to improperly fitting shoes and sore feet. When assessing the client’s feet, the nurse notes a bunion and refers the client to a podiatrist. Place an X on the illustration where the nurse noted the bunion.

532.A client has a DEXA (dual-energy x-ray absorptio metry) scan that reveals osteoporosis. Which medica tion, if taken by the 62-year-old client, should a nurse identify as posing a secondary risk factor for the client’s osteoporosis?. 1. Baby aspirin daily for past 4 years. 2. Escitalopram (Lexapro®) 5 mg daily for past 7 months. 3. Multivitamin for many years. 4. Budesonide (Pulmicort®) two sprays to each nostril two times a day for 9 to 10 years.

533.When assessing an older adult, which tools should a nurse select to identify the client’s needs and care deficits?. 1. Katz Index of Activities of Daily Living. 2. Maslow’s Hierarchy of Needs. 3. Mini Mental State Exam (MMSE). 4. Erikson’s Developmental Task Theory.

534.A 74-year-old client is admitted from the emergency department after sustaining a knife cut to the left hand. The client has a dry and intact dressing on the left hand and has IV D5LR infusing at 100 mL/minute in the right hand. A nurse, perform ing the health assessment, writes a nursing diagnosis: Disturbed thought processes due to inability to focus and memory deficits. In analyzing the assessment data, the nurse determines that the signs supporting this nursing diagnosis may be a result of the client: SELECT ALL THAT APPLY. 1. receiving pain medication in the ER. 2. having possible early dementia. 3. not eating dinner. 4. experiencing a strange environment. 5. feeling anxious about hospitalization.

535.A 76-year-old client is admitted to a surgical unit fol lowing a right colectomy for a small tumor. The client has lactated Ringer’s solution infusing intravenously at 125 mL/hr, O2 per nasal cannula at 3 L, and a right abdominal dressing. A nurse analyzes the client’s as sessment information and identifies the nursing diag nosis: Risk for infection (pneumonia) due to age related functional changes in the respiratory system. Which age-related assessment most likely prompted the nurse to establish the nursing diagnosis?. 1. Decreased residual volume. 2. Increased vital capacity. 3. Increased PaO2. 4. Decreased cough reflex.

535.A 76-year-old client is admitted to a surgical unit fol lowing a right colectomy for a small tumor. The client has lactated Ringer’s solution infusing intravenously at 125 mL/hr, O2 per nasal cannula at 3 L, and a right abdominal dressing. A nurse analyzes the client’s as sessment information and identifies the nursing diag nosis: Risk for infection (pneumonia) due to age related functional changes in the respiratory system. Which age-related assessment most likely prompted the nurse to establish the nursing diagnosis?. 1. Decreased residual volume. 2. Increased vital capacity. 3. Increased PaO2. 4. Decreased cough reflex.

536.An 84-year-old client, hospitalized for repair of a fractured hip, is incontinent of urine, is sometimes confused, and is not eating well. A nurse notes non blanchable erythema of the intact skin over the client’s coccyx. The nurse’s interventions to prevent further skin breakdown should include: SELECT ALL THAT APPLY. 1. relieving pressure under the coccyx with an inflatable “donut.”. 2. repositioning the client at least every 2 hours. 3. keeping the head-of-bed raised above 30 degrees. 4. careful skin hygiene and reduction of pressure over the coccyx. 5. offering foods the client likes to eat.

537. A nurse obtains information for a 75-year-old client and concludes that some findings are not age related and require further follow-up because the client is at risk for falls. Which report by the client represents a non-age-related finding that requires additional investigation?. 1. Reports experiencing a decreased ability to see at night. 2. Reports seeing halos around lights. 3. Reports having difficulty distinguishing some colors. 4. Reports diminished visual acuity.

538.A nurse is admitting an older adult client to a hospital medical unit. The nurse’s assessment findings in clude:blood pressure (BP) 96/64 mm Hg,pulse 118/minute,respirations 20/minute,weight 110 pounds with an 8-pound weight loss in the last 3 months due to severe loss of appetite from chemotherapy for breast cancer,and body mass index (BMI) of 19. The client reports fatigue and decreased mobility (able to get around the house,but does not go out). Though tired, the client responds appropri ately and clearly to questions and denies psychologi cal problems. Which score should the nurse assign to the client when completing the Geriatric Mini Nutrition Assessment?. 1.Score of 3. 2.Score of 4. 3.Score of 5. 4.Score of 6.

539.For which reason should a nurse plan to teach an older, hospitalized client about newly prescribed medications?. 1. Most older adult clients are unable to read the unit developed printed teaching materials. 2. Hospital admissions and readmissions of older adult clients occur from misuse of medications. 3. Most older adult clients are unable to retain information from printed teaching materials. 4. The client needs understanding of medications before prescriptions can be filled.

540.A client’s family approaches a nurse with a complaint about a nursing assistant’s inappropriate communica tion with their 89-year-old father. When evaluating the nursing assistant’s communication, which state ment most likely caused the family’s complaint?. 1. “Are you ready for the nurse to give you your medicine?”. 2. “Grandpa, would you like to go to breakfast now?”. 3. “Would you prefer to wear the brown socks today?”. 4. “Your family will be visiting today. Isn’t that nice?”.

541. At a community senior meal program, a nurse in quires about the health of an 80-year-old female attendee. The woman states that she is not taking her medication because it is too expensive and not needed. Based on knowledge of gerontological nurs ing, the nurse should recognize that the client is most likely refusing her medication because she: 1. has insufficient knowledge to realize that the medication is good for her. 2. is in a bad mood today and is being obstinate. 3. fears she will live longer than her resources will last. 4. prefers the sick role because it allows her to be “waited on.”.

542.An 87-year-old client, recovering from hip surgery, is ordered oxycodone (OxyContin®) as needed for pain. After giving this medication, for which side effects should a nurse assess the client?. 1. Blood glucose elevation. 2. Respiratory alkalosis. 3. Urinary retention. 4. Loss of appetite.

543.An 85-year-old client is hospitalized for diverticulitis. The client’s 83-year-old girlfriend spends most of the day and evening with him. Several nurses have made comments about the couple’s relationship. Which nurse’s comment represents a myth about the inti macy needs of older adults in general?. 1. Older adults require less physical contact than younger adults. 2. Sexual expression may enhance the quality of life of older adults. 3. Sexual expression may be difficult or impossible for some older adults. 4. Sexual interest tends to persist throughout one’s life span.

544.A nurse is caring for an 80-year-old hospitalized client of the Muslim belief who is near death. Which nursing action is most inappropriate?. 1. Perfuming the room. 2. Positioning the client supine facing Mecca. 3. Offering grief counseling to family members. 4. Reviewing the medical records to determine if the client wishes organ donation.

545.A 72-year-old male client with terminal cancer is re ceiving palliative care services in his home. He com ments to the nurse, “I am such a feeble old man. My life is such a waste, and I hate having my wife see me like this. I just wish I could die now.” The nurse’s best interpretation of these comments is that the client is: 1. ashamed and ready to die. 2. expressing anxiety due to the diagnosis of terminal cancer. 3. experiencing Havighurst’s developmental tasks of later maturity. 4. experiencing Erikson’s developmental state of integrity versus despair.

546.A client’s plan of care includes a nursing diagnosis of Anticipatory grieving/death anxiety related to antici pated loss of physiological well-being. A nurse evalu ates that the client has achieved one desired outcome pertinent to the diagnosis when the client: 1. dies with family members present. 2. continues normal life activities within abilities and verbalizes taking 1 day at a time. 3. verbalizes experiencing negative death images and unpleasant thoughts. 4. states worries about causing grief and suffering in others.

547.A physician notifies the family of the death of their 90-year-old mother who died on admission to the emergency room. A nurse is meeting the family for the first time to escort them to the client’s room. Which initial statement by the nurse would be best?. 1. “I’m very sorry for the loss of your mother.”. 2. “This must be very hard for you. You have my sympathy.”. 3. “I am the nurse who was with your mother when she died.”. 4. “Let me take you to your mother’s room where we can talk and you can be alone with her.”.

548.An 89-year-old client has recently been widowed. A nurse counseling the client explains that the client may experience grief for many years and may likely go through the phases of grief. Place each phase of the grief process in the correct order. ______ Full effects of widowhood set along with regret, self-doubt, and at times despair. ______ Numb shock where the widow cannot believe that the spouse’s death occurred. ______ Reorganization with positive outlook on life and positive coping strategies. ______ Emotional turmoil with alarm or panic-type reactions and anger, guilt, or longing.

549. An 89-year-old female widow, who has been a resident of a long-term care facility for 2 years, is now incapac itated due to recurrent multiple strokes. A new nurse asks the client’s only daughter to identify the goal for her mother’s care and decide what interventions should be instituted should the resident develop acute prob lems. Which statement made by the new nurse should prompt an experienced nurse to intervene?. 1. “If your mother should experience a cardiac arrest, should an attempt be made to resuscitate her?”. 2. “If your mother should develop an acute illness, such as pneumonia, how aggressively should she be treated, and should she be transferred to an acute care facility?”. 3. “If your mother should stop eating, should she be force fed, supplied artificial nutrition, or receive gentle spoon-feeding?”. 4. “If your mother has another stroke, should she receive her regular hygienic and activity care, prescribed medications, and have regular visitors?”.

550.An 87-year-old client has severe coronary artery dis ease and has been advised to complete a living will and a durable power of attorney for health care. The client asks, “Why do I need both?” A nurse explains that a living will differs from a durable power of at torney in that a living will: 1. is an example of an advanced health-care directive. 2. allows the client to designate a person to make decisions should the client become unable to provide informed consent for health-care decisions. 3. provides a legal document for the client to specify what type of medical treatment is desired should the client becomes incapacitated and terminally ill. 4. is not a legal document, but makes it easier and quicker for medical personnel to care for the client if the client becomes terminally ill.

551. An 82-year-old client is hospitalized for the fifth time within a year. The client’s problems include urinary track infection, myocardial infarction, stroke, and gas trointestinal bleeding. The client’s physician recom mends discharge to a nursing home, but the client re fuses, stating, “As long as I can take care of myself, I’m not going into a home!” Assuming that the client is mentally competent, which ethical principle should be the primary guide for making decisions about support ing or rejecting the client’s desire to return to home?. 1. Autonomy. 2. Beneficence. 3. Nonmalfeasance. 4. Justice.

552.A nurse is evaluating the blood pressure (BP) results for multiple clients with cardiac problems on a telemetry unit. Which BP reading suggests to the nurse that the client’s mean arterial pressure (MAP) is abnormal and warrants notifying the physician?. 1.94/60 mm Hg. 2.98/36 mm Hg. 3.110/50 mm Hg. 4.140/78 mm Hg.

553.A nurse is assessing an older adult admitted with a diagnosis of left-sided heart failure and mitral regur gitation. Identify the area with an X where the nurse should place the stethoscope to best auscultate the murmur associated with mitral regurgitation.

554.At 0730 hours,a nurse receives a verbal order for a cardiac catheterization to be completed on a client at 1400 hours. Which action should the nurse initiate first?. 1.Initiate NPO (nothing per mouth) status for the client. 2.Teach the client about the procedure. 3.Start an intravenous (IV) infusion of 0.9% NaCl. 4.Ask the client to sign a consent form.

555.Blood for cardiac enzymes and serum laboratory tests are drawn on a diabetic client admitted to an emer gency department (ED) 5 hours after beginning to ex perience chest pressure. A nurse reviews the follow ing laboratory results. Which serum laboratory findings should the nurse report to a primary health care provider (HCP) immediately due to the possibil ity that the client may be experiencing a myocardial infarction (MI)? SELECT ALL THAT APPLY. 1.SCr. 2.PT/INR. 3.CK. 4.CK-MB. 5.Platelets. 6.Troponin T.

556.A nurse assesses a client who has just returned to a telemetry unit after having a coronary angiogram us ing the left femoral artery approach. The client’s baseline blood pressure (BP) during the procedure was 130/72 mm Hg and the cardiac rhythm was a normal sinus throughout. Which assessment finding should indicate to the nurse that the client may be ex periencing a complication?. 1. BP 144/78 mm Hg. 2. Pedal pulses palpable at +1. 3. Left groin soft with 1 cm ecchymotic area. 4. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm.

557. A nurse admits a client to a telemetry unit and ob tains the following electrocardiogram (ECG) strip of the client’s heart rhythm. What should be the nurse’s interpretation of this rhythm strip?. 1. Atrial flutter. 2. Atrial fibrillation. 3. Sinus bradycardia. 4. Sinus rhythm with premature atrial contractions (PACs).

558. Anurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the health-care provider is likely to initially order: SELECT ALL THAT APPLY. 1. oxygen. 2. immediate cardioversion. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 5. immediate catheter-directed ablation of the AV node. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem®).

559.A nurse is caring for a client immediately following insertion of a permanent pacemaker via the right sub clavian vein approach. The nurse best prevents pace maker lead dislodgement by: 1. inspecting the incision site dressing for bleeding and the incision for approximation. 2. limiting the client’s right arm activity and preventing the client reaching above shoulder level. 3. assisting the client with getting out of bed and ambulating with a walker. 4. ordering a stat chest x-ray following return from the implant procedure.

560. Aclient experiences cardiac arrest at home and is successfully resuscitated. Following placement of an implantable cardioverter-defibrillator (ICD), a nurse is evaluating the effectiveness of teaching for the client. Which statement, if made by the client, indicates that further teaching is needed?. 1. “The ICD will monitor my heart activity and provide a shock to my heart if my heart goes into ventricular fibrillation again.”. 2. “When I feel the first shock I should tell my family to start cardiopulmonary resuscitation (CPR) and call 911.”. 3. “I am fearful of my first shock since my friend stated his shock felt like a blow to the chest.”. 4. “I will need to ask my physician when I can resume driving because some states disallow driving until there is a 6-month discharge-free period.”.

561. A nurse is teaching a client newly diagnosed with chronic stable angina. Which instructions should the nurse incorporate in the teaching session on measures to prevent future angina? SELECT ALL THAT APPLY. 1. Increase isometric arm exercises to build endurance. 2. Wear a face mask when outdoors in cold weather. 3. Take nitroglycerin before a stressful situation even though pain is not present. 4. Perform most exertional activities in the morning. 5. Avoid straining at stool. 6. Eliminate tobacco use.

562. Anurse collects the following assessment data on a client who has no known health problems: blood pressure (BP) 135/89 mm Hg; body mass index (BMI) 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum K 4.0 mEq/L; low-density lipopro tein (LDL) cholesterol 200 mg/dL; high-density lipoprotein (HDL) cholesterol 25 mg/dL; and triglyc erides 180 mg/dL. Which order from the client’s health-care provider should the nurse anticipate?. 1. 1,500-calorie regular diet. 2. No added salt, low saturated fat, low-potassium diet. 3. Hydrochlorothiazide (HydroDIURIL®) 25 mg twice daily. 4. Atorvastatin (Lipitor®) 20 mg daily.

563.A nurse is instructing a client diagnosed with coro nary artery disease about care at home. The nurse determines that teaching is effective when the client states: SELECT ALL THAT APPLY. 1. “If I have chest pain, I should contact my physician immediately.”. 2. “I should carry my nitroglycerin in my front pants pocket so it is handy.”. 3. “If I have chest pain, I stop activity and place one nitroglycerin tablet under my tongue.”. 4. “I should always take three nitroglycerin tablets, 5 minutes apart.”. 5. “I plan to avoid being around people when they are smoking.”. 6. “I plan on walking on most days of the week for at least 30 minutes.”.

564. Aclient admitted with a diagnosis of acute coronary syndrome calls for a nurse after experienc ing sharp chest pains that radiate to the left shoulder. The nurse notes, prior to entering the client’s room, that the client’s rhythm is sinus tachycardia with a 10-beat run of premature ventricular contractions (PVCs). Admitting orders included all of the follow ing interventions for treating chest pain. Which should the nurse implement first?. 1. Obtain a stat 12-lead electrocardiogram (ECG). 2. Administer oxygen by nasal cannula. 3. Administer sublingual nitroglycerin. 4. Administer morphine sulfate intravenously.

565.A nurse is assessing a client diagnosed with an anterior-lateral myocardial infarction (MI). The nurse adds a nursing diagnosis to the client’s plan of care of decreased cardiac output when which finding is noted on assessment?. 1. One-sided weakness. 2. Presence of an S4 heart sound. 3. Crackles auscultated in bilateral lung bases. 4. Vesicular breath sounds over lung lobes.

566.A nurse increases activity for a client with an admit ting diagnosis of acute coronary syndrome. Which symptoms experienced by the client best support a nursing diagnosis of activity intolerance?. 1. Pulse rate increased by 15 beats per minute during activity. 2. Blood pressure (BP) 130/86 mm Hg before activity; BP 108/66 mm Hg during activity. 3. Increased dyspnea and diaphoresis relieved when sitting in a chair. 4. A mean arterial pressure (MAP) of 80 following activity.

567. After an inferior-septal wall myocardial infarction, which complication should a nurse suspect when not ing jugular venous distention (JVD) and ascites?. 1. Left-sided heart failure. 2. Pulmonic valve malfunction. 3. Right-sided heart failure. 4. Ruptured septum.

568. Which nursing actions should a nurse plan when caring for a client experiencing dyspnea due to heart failure and chronic obstructive pulmonary disease (COPD)? SELECT ALL THAT APPLY. 1. Apply oxygen 6 liters per nasal cannula. 2. Elevate the head of the bed 30 to 40 degrees. 3. Weigh client daily in the morning. 4. Teach client pursed-lip breathing techniques. 5. Turn and reposition the client every 1 to 2 hours.

569.A nurse notes that a client, who experienced a myo cardial infarction (MI) 3 days ago, seems unusually fatigued. Upon assessment, the nurse finds that the client is dyspneic with activity, has a heart rate (HR) of 110 beats per minute (bpm), and has generalized edema. Which action by the nurse is most appropriate?. 1. Administer high-flow oxygen. 2. Encourage the client to rest more. 3. Continue to monitor the client’s heart rhythm. 4. Compare the client’s admission weight with the client’s current weight.

570.A client is hospitalized for heart failure secondary to alcohol-induced cardiomyopathy. The client is started on milrinone (Primacor®) and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the med ication orders, overall care, and the need for energy conservation. A nurse should interpret that the client’s behavior is likely related to the client’s: 1. denial of the illness. 2. reaction to milrinone (Primacor®). 3. fear of the diagnosis. 4. response to cerebral anoxia.

571. A client diagnosed with class II heart failure according to the New York Heart Association Func tional Classification has been taught about the initial treatment plan for this disease. A nurse determines that the client needs additional teaching if the client states that the treatment plan includes: 1. diuretics. 2. a low-sodium diet. 3. home oxygen therapy. 4. angiotensin-converting enzyme (ACE) inhibitors.

572.A client is admitted with a diagnosis of acute infec tive endocarditis (IE). Which findings during a nurs ing assessment support this diagnosis? SELECT ALL THAT APPLY. 1. Skin petechiae. 2. Crackles in lung bases. 3. Peripheral edema. 4. Murmur. 5. Arthralgia. 6. Decreased erythrocyte sedimentation rate (ESR).

573. A nurse evaluates that a client understands dis charge teaching, following aortic valve replacement surgery with a synthetic valve, when the client states that he/she plans to: SELECT ALL THAT APPLY. 1. use a soft toothbrush for dental hygiene. 2. floss teeth daily to prevent plaque formation. 3. wear loose-fitting clothing to avoid friction on the sternal incision. 4. use an electric razor for shaving. 5. report black, tarry stools. 6. consume foods high in vitamin K, such as broccoli.

574. A male client confides to a clinic nurse that he is no longer dyspneic after receiving his new St. Jude’s heart valve. He wants to have a vasectomy so that he can enjoy sexual intercourse again without the fear of his wife becoming pregnant. What is the nurse’s best response?. 1. “That’s probably a good idea. The life expectancy after heart valve replacement is 10 to 15 years.”. 2. “You seem relieved that the heart valve replacement was successful and that you can enjoy a normal life again.”. 3. “If you have cardiac symptoms such as dyspnea during sexual intercourse, you can take a nitroglycerin tablet before sexual activity to prevent symptoms.”. 4. “Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventive measure before the procedure.”.

575. A client admitted with unstable angina is started on intravenous heparin and nitroglycerin. The client’s chest pain resolves, and the client is weaned from the nitroglycerin. Noting that the client had a synthetic valve replacement for aortic stenosis 2 years ago, a physician writes an order to restart the oral warfarin (Coumadin®) 5 mg at 1900 hours. Which is the nurse’s best action?. 1. Administer the warfarin as prescribed. 2. Call the physician to question the warfarin order. 3. Discontinue the heparin drip and then administer the warfarin. 4. Hold the dose of warfarin until the heparin has been discontinued.

576. A nurse is caring for a client following a coro nary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse?. 1. No chest tube output for 1 hour when previously it was copious. 2. Client temperature of 99.1°F (37.2°C). 3. Arterial blood gas (ABG) results show pH 7.32; Pco2 48; HCO3 28; Po2 80. 4. Urine output of 160 mL in the last 4 hours.

577. Anurse should anticipate instructing a client scheduled for a coronary artery bypass graft to: SELECT ALL THAT APPLY. 1.discontinue taking aspirin prior to surgery. 2.perform postoperative cardiac rehabilitation exercises and stress management strategies. 3.wash with an antimicrobial soap the evening prior to surgery. 4.shave the chest and legs and then shower to remove the hair. 5.resume normal activities when discharged from the hospital. 6.expect close monitoring after surgery,several intravenous (IV) lines,a urinary catheter, endotracheal tube,and chest tubes.

578.Because a step-down cardiac unit is unusually busy, a nurse fails to obtain vital signs at 0200 hours for a client 2 days postoperative for a mitral valve re placement. The client was stable when assessed at 0600 hours,so the nurse documents the electrocar diogram monitor’s heart rate in the client’s medical record for both the 0400 and 0600 vital signs. The charge nurse supervising the nurse determines that the nurse’s behavior was:SELECT ALL THAT APPLY. 1. the correct action because neither complications nor harmful effects occurred. 2.a legal issue because the nurse has fraudulently falsified documentation. 3.demonstrating beneficence because the nurse decided what was best for the client. 4.an ethical issue of veracity because the nurse has been untruthful regarding the client’s care. 5.an ethical legal issue of confidentiality because the nurse disclosed incorrect information. 6.demonstrating distributive justice because the nurse decided other clients’needs were priority.

579.A nurse,assessing a client hospitalized following a myocardial infarction (MI),obtains the following vital signs:blood pressure (BP) 78/38 mm Hg,heart rate (HR) 128,respiratory rate (RR) 32. For which life-threatening complication should the nurse care fully monitor the client?. 1.Pulonary embolism. 2.Cardiac tamponade. 3.Cardiomyopathy. 4.Cardiogenic shock.

580.A client is admitted to a coronary care unit following an anterior myocardial infarction (MI). A nurse,car ing for the client,obtains the following assessment findings. Based on these findings, the nurse should immediately notify the physician and plan which intervention?. 1.Administering an IV fluid bolus of 0.9% NaCl because the client is in right heart failure. 2.Initiating an IV infusion of dopamine (Intropin®) because the client is in cardiogenic shock. 3.Preparing the client for pericardiocentesis since cardiac tamponade is suspected. 4.Calling for a stat chest x-ray to rule out pulmonary embolism (PE).

581.A client admitted to a telemetry unit with a diagnosis of Prinzmetal’s angina, has the following medications ordered. Upon interpretation of the client’s electro cardiogram (ECG) rhythm, the nurse notes a prolonged PR interval of 0.32 second. Based on this information, which medication order should the nurse question administering to the client?. 1. Isosorbide mononitrate (Imdur®) 20 mg oral daily upon awakening. 2. Amlodipine (Norvasc®) 10 mg oral daily. 3. Nitroglycerin (Nitrostat®) 0.4 mg sublingual prn for chest pain. 4. Atenolol (Tenormin®) 50 mg oral daily.

582. A nurse is to administer 40 mg of furosemide (Lasix®) to a client in heart failure. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, the nurse should administer ____mL to the client.

583. Anurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. After reviewing all of the lab reports, in which order should the nurse address each lab value? Priori tize the order in which the nurse should address each of the clients’ results. ______ Troponin T 42 ng/mL (0.0–0.4 ng/mL). ______ WBC 11,000 K/µL. ______ Hgb 7.2 g/dL. ______ SCr 2.2 mg/dL. ______ K 2.2 mEq/L. ______ Total cholesterol 430 mg/dL.

584. Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to re move the chest tubes. Which intervention should the nurse plan to implement first?. 1. Auscultate the client’s lung sounds. 2. Administer 4 mg morphine sulfate intravenously. 3. Turn off the suction to the chest drainage system. 4. Prepare the dressing supplies at the client’s bedside.

585.A nurse who is beginning a shift on a cardiac step down unit receives shift report for four clients. In which order should the nurse assess the clients? Prioritize the nurse’s actions by placing each client in order from most urgent (1) to least urgent (4). ______ A 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes. ______ A 62-year-old client with end-stage cardiomyopathy,blood pressure (BP) of 78/50 mm Hg,20 mL/hr urine output,and a “Do Not Resuscitate”order and whose family has just arrived. ______ A 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new onset atrial fibrillation with rapid ventricular response. ______ A 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg,heart rate (HR) 100 beats/min,respiratory rate (RR) 28 breaths/min,and temperature 101.2°F (38.4°C).

586.A nurse is working with a certified nursing assistant (CNA) providing care for four clients on a busy telemetry unit. All four clients are in need of immedi ate attention. The CNA is a senior nursing student who has been administering medications and per forming procedures during clinical experiences as a student nurse. The charge nurse supervising care on the telemetry unit determines that care is appropriate when the registered nurse (RN) working with the CNA delegates:SELECT ALL THAT APPLY. 1.administering acetaminophen (Tylenol®) to the client with an elevated temperature. 2.taking vital signs on the client newly admitted with a diagnosis of heart failure. 3.finishing the discharge instructions so the client with a new pacemaker implant can go home. 4.changing a client’s chest tube dressing because it got wet when the water pitcher overturned. 5.providing a sponge bath for the client with the elevated temperature. 6.checking the lung sounds of the client whose chest tube drainage system was tipped over and then righted.

587. Anurse is reviewing serum laboratory data for four female clients. Which client would require the most immediate assessment?. 1. Client A. 2. Client B. 3. Client C. 4. Client D.

588.A clinic nurse is evaluating a client with type 1 dia betes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand?. 1. “I will carry a high-fat, high-calorie food, such as a cookie.”. 2. “I will administer 1 unit of lispro insulin prior to playing tennis.”. 3. “I will eat a 15-gram carbohydrate snack before playing tennis.”. 4. “I will decrease the meal prior to the class by 15-grams of carbohydrates.”.

589. Two hours after taking a regular morning dose of Insulin Regular (Humulin R®), a client presents to a clinic with diaphoresis, tremors, palpitations, and tachy cardia. Which nursing action is most appropriate for this client?. 1. Check pulse oximetry and administer oxygen at 2 L per nasal cannula. 2. Administer a baby aspirin, one sublingual nitroglycerin tablet, and obtain an electrocardiogram (ECG). 3. Check blood glucose level and provide carbohydrates if less than 70 mg/dL (3.8 mmol/L). 4. Check vital signs and administer atenolol (Tenormin®) 25 mg orally if heart rate is greater than 120 beats per minute.

590.A nurse working on a telemetry unit is planning to complete noon assessments for four assigned clients with type 1 diabetes mellitus. All of the clients re ceived subcutaneous insulin aspart (NovoLog®) at 0800 hours. In which order should the nurse assess the clients? Place each answer option into the correct order. _____ A 60-year-old client who is nauseous and has just vomited for the second time. _____ A 45-year-old client who is dyspneic and has chest pressure and new onset atrial fibrillation. _____ A 75-year-old client with a fingerstick blood glucose level of 300 mg/dL. _____ A 50-year-old client with a fingerstick blood glucose level of 70 mg/dL.

591.A client has eaten 45 grams of carbohydrate (carb) with the dinner meal. The client is ordered to receive 2 units of aspart insulin subcutaneously for each carb choice (CHO) eaten at a meal (1 carb choice =15 grams). Place an X on the syringe that correctly identi fies the amount of insulin the client should receive.

592.A nurse is caring for a client with type 2 diabetes on a telemetry unit. The client is scheduled for car diac rehabilitation exercises (cardiac rehab). The nurse notes that the client’s blood glucose level is 300 mg/dL and the urine is positive for ketones. Which nursing action should be included in the nurse’s plan of care?. 1. Send the client to cardiac rehab because exercise will lower the client’s blood glucose level. 2. Administer insulin and then send the client to cardiac rehab with a 15-gram carbohydrate snack. 3. Delay the cardiac rehab because blood glucose levels will decrease too much with exercise. 4. Cancel the cardiac rehab because blood glucose levels will increase further with exercise.

593. Anurse administers 15 units of glargine (Lantus®) insulin at 2100 hours to a Hispanic client when the client’s fingerstick blood glucose reading was 110 mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruc tion by the nurse is most appropriate?. 1. “You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime.”. 2. “It is not necessary for this client to have a snack because glargine insulin is absorbed very slowly over 24 hours and doesn’t have a peak.”. 3. “The next time the client wakes up, check a blood glucose level and then give a snack.”. 4. “I will need to notify the physician because a snack at this time will affect the client’s blood glucose level and the next dose of glargine insulin.”.

594.A client diagnosed with diabetes mellitus is on an insulin infusion drip. The insulin bag indicates there are 100 units of insulin in 1,000 milliliters (mL) of normal saline. Based on the client’s blood glucose reading, the client should receive 1.5 units per hour. To ensure that the client receives 1.5 units per hour, the nurse should set the pump at ______ mL/hr.

595. Anurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize?. 1. Use the arm when self-administering NPH insulin. 2. Exercise for 30 minutes daily, preferably after a meal. 3. Consume 30% of the daily calorie intake from protein foods. 4. Eat a 30-gram carbohydrate snack prior to strenuous activity.

596.A nurse is evaluating a client’s outcome. The client’s nursing care plan includes the nursing diagnosis of fluid volume deficit related to hyperosmolar hyper glycemic nonketotic syndrome (HHNS) secondary to severe hyperglycemia. The nurse knows that the client has a positive outcome when which serum laboratory value has decreased to a normal range?. 1. Glucose. 2. Sodium. 3. Osmolality. 4. Potassium.

597.A client with type 1 diabetes mellitus is scheduled for a total hip replacement. In reviewing the client’s or ders the evening prior to surgery, a nurse notes that the physician did not write an order to change the client’s daily insulin dose. Which nursing action is most appropriate?. 1. Notify the physician who wrote the insulin order in the client’s medical record. 2. Write an order to decrease the morning insulin dose by one-half of the prescribed morning dose. 3. Do nothing because the physician would want the client to receive the usual insulin dose prior to surgery. 4. Inform the day shift nurse to check the client’s fingerstick glucose before surgery and hold the morning dose of insulin.

598.A nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 a.m. to a client with a blood glucose level of 110 mg/dL. Which statements regarding the client’s insulin are correct?. 1. The onset of the regular insulin will be at 7:45 a.m. and the peak at 1:00 p.m. 2. The onset of the regular insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 3. The onset of the NPH insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 4. The onset of the NPH insulin will be at 12:30 p.m. and the peak at 11:30 p.m.

599. Ahome-health nurse is planning the first home visit for a 60-year-old Hispanic client newly diag nosed with type 2 diabetes mellitus. The client has been instructed to take 70/30 combination insulin in the morning and at suppertime. Which interventions should be included in the client’s plan of care? SELECT ALL THAT APPLY. 1. Instruct the client to inspect the feet daily. 2. Ensure that the client eats a bedtime snack. 3. Assess the client’s ability to read small print. 4. Teach the client how to perform a hemoglobin A1c test. 5. Instruct the client on storing prefilled syringes in the refrigerator. 6. Teach the client to take one unit of 70/30 insulin after eating a snack.

600.A friend brings an older adult homeless client to a free health-screening clinic because the friend is un able to continue administering the client’s morning and evening insulin for type 1 diabetes mellitus. When advocating for this client, which action by the nurse is most appropriate?. 1. Notify Adult Protective Services about the client’s condition and living situation. 2. Ask where the client lives and if someone else can administer the insulin. 3. Contact the unit social worker to arrange for someone to give the client’s insulin at a local homeless shelter. 4. Have the client return to the screening clinic mornings and evenings to receive the insulin injections.

601. Which physician’s order should the nurse question for a newly admitted client diagnosed with diabetic ketoacidosis (DKA)?. 1. D5W at 125 mL per hour. 2. KCL 10 mEq in 100 mL NaCl IV now. 3. Stat arterial blood gases. Administer sodium bicarbonate if pH is less than 7.0. 4. Regular insulin infusion per protocol adjusting dose based on hourly glucose levels.

602. Which instructions should the nurse provide to a client regarding diabetes management during stress or illness? SELECT ALL THAT APPLY. 1. Notify the health-care provider if unable to keep fluids or foods down. 2. Test fingerstick glucose levels and urine ketones daily and keep a record. 3. Continue to take oral hypoglycemic medications and/or insulin as prescribed. 4. Supplement food intake with carbohydrate containing fluids, such as juices or soups. 5. When on an oral agent, administer insulin in addition to the oral agent during the illness. 6. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs.

603.A nurse evaluates a client who is being treated for diabetic ketoacidosis (DKA). Which finding indicates that the client is responding to the treatment plan?. 1. Eyes sunken, skin flushed. 2. Skin moist with rapid elastic recoil. 3. Serum potassium level is 3.3 mEq/L. 4. ABG results are pH 7.25, PaCO2 30, HCO3 17.

604.A nurse is documenting nursing diagnoses for a client with elevated growth hormone (GH) levels. Which nursing diagnosis is least likely to be included in the client’s plan of care?. 1. Fluid volume deficit related to polyuria. 2. Insomnia related to soft tissue swelling. 3. Impaired communication related to speech difficulties. 4. Disturbed body image related to undersized hands, feet, jaw, and soft body tissue.

605.Which nursing actions are most appropriate when caring for a client diagnosed with diabetes insipidus (DI)? SELECT ALL THAT APPLY. 1. Monitoring fingerstick blood glucose before meals and at bedtime. 2. Monitoring urine output hourly. 3. Checking urine ketones. 4. Administering desmopressin acetate (DDAVP). 5. Monitoring for signs of hyperkalemia. 6. Monitoring daily weights.

606. Aclient has developed syndrome of inappropri ate antidiuretic hormone (SIADH) secondary to a pituitary tumor. The client’s symptoms include thirst, weight gain, and fatigue. The client’s serum sodium is 127 mEq/L. Which physician order should the nurse anticipate when treating SIADH?. 1. Elevate the head of the bed. 2. Administer vasopressin intravenously (IV). 3. Fluid restriction of 800 to 1,000 mL per day. 4. 0.3% sodium chloride IV infusion.

607. Which finding should the nurse anticipate when assessing a client newly diagnosed with diabetes insipidus (DI)?. 1. Polyuria. 2. Weight gain. 3. Hyperglycemia. 4. Profuse sweating and flushed skin.

608.A client taking thyroid replacement hormone was in volved in an automobile accident in another state and was hospitalized for a femur fracture. The physician did not prescribe replacement hormone because the client’s medication history was unknown and the client was a poor historian at the time of the accident due to pain. A week after being hospitalized, a nurse notes that the client is becoming increasingly lethar gic. Vital signs show a decreased blood pressure, res piratory rate, temperature, and pulse. Which actions should be taken by the nurse? Place each nursing action in the order of priority. ____ Warm the client. ____ Administer intravenous fluids. ____ Assist in ventilatory support. ____ Administer the prescribed thyroxine.

609.A nurse is assessing a client following a total thy roidectomy. The client has a positive Trousseau’s sign. Place an X on the illustration that supports the nurse’s assessment finding.

610. An agitated client is admitted to the emergency department (ED) with tachycardia, dyspnea, and in termittent chest palpitations. The client has a blood pressure of 170/110 mm Hg and heart rate of 130 beats per minute. The client’s health history reveals thinning hair, recent 10-lb. weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth moist skin. A physician writes orders for the client. Which order should the nurse implement first?. 1. Obtain 12-lead electrocardiogram (ECG). 2. Administer propranolol (Inderal®) 2 mg intravenously q10–15min or until symptoms are controlled. 3. Administer propylthiouracil (PTU) 600 mg oral loading dose followed by 200 mg orally q4h. 4. Obtain thyroid-stimulating hormone (TSH), free T4, and cardiac enzyme levels.

611. A clinic nurse is teaching a client who has been diag nosed with hypothyroidism. Which instructions should the nurse provide regarding the use of levothyroxine sodium (Synthroid®)? SELECT ALL THAT APPLY. 1. Take the medication 1 hour before or 2 hours after breakfast. 2. Obtain a pulse rate before taking the medication, and call the clinic if the pulse rate is greater than 100 beats per minute. 3. Report adverse effects of the medication, including weight gain, cold intolerance, and alopecia. 4. Use levothyroxine sodium (Synthroid®) as a replacement hormone for diminished or absent thyroid function. 5. Have frequent laboratory monitoring to be sure your levels of T3 and T4 decrease.

612.A nurse is caring for a client who had a thyroidec tomy 2 days ago. Based on the findings of the client’s serum laboratory report, which medication should the nurse plan to administer first. 1. K-dur® 20 mEq oral (PO) bid. 2. Calcium gluconate 4.5 mEq intravenously (IV). 3. Dolasetron (Anzemet®) 12.5 mg IV as needed. 4. Levothyroxine (Synthroid®) 50 mcg PO daily.

613.A clinic nurse evaluates that a client’s levothyroxine (Synthroid®) dose is too low when which findings are noted? SELECT ALL THAT APPLY. 1. Increased appetite. 2. Decreased sweating. 3. Apathy and fatigue. 4. Paresthesias. 5. Fine tremor of fingers and tongue. 6. Slowed mental processes.

614. Which nursing diagnosis should a nurse include when developing a plan of care for a client with hypothyroidism?. 1. Diarrhea related to gastrointestinal hypermotility. 2. Imbalance nutrition: less than body requirements related to calorie intake insufficient for metabolic rate. 3. Activity intolerance related to increased metabolic rate. 4. Anxiety related to forgetfulness, slowed speech, and impaired memory loss.

615. A female client is being treated with radioactive iodine (RAI) therapy for an enlarged thyroid gland. The client asks if there are any precautions that are needed during RAI therapy. Which is the nurse’s best response?. 1. “No precautions are necessary. You receive radiation in the form of a capsule that will target and destroy the thyroid tissue only.”. 2. “Though a pregnancy test has confirmed that you are not pregnant, use contraceptives or abstain from sexual intercourse to avoid conceiving during treatment.”. 3. “Because maximum effects may not be seen for 6 months, you will need to continue taking the antithyroid medication and propranolol until the effects of radiation become apparent.”. 4. “Although RAI is usually effective, a few individuals will need life-long thyroid hormone replacement due to posttreatment hypothyroidism.”.

616. A nurse is teaching a client experiencing hypoparathyroidism resulting from a lack of parathyroid hormone (PTH) about foods to consume. Which should be included on a list of appropriate foods for a client experiencing hypoparathyroidism?. 1. Dark green vegetables, soybeans, and tofu. 2. Spinach, strawberries, and yogurt. 3. Whole grain bread, milk, and liver. 4. Rhubarb, yellow vegetables, and fish.

617. Which nursing diagnoses should the nurse doc ument in the plan of care for a client diagnosed with Cushing’s syndrome? SELECT ALL THAT APPLY. 1. Fluid and electrolyte imbalance related to hyperkalemia and hypernatremia. 2. Body image disturbance related to weight gain and facial hair. 3. Risk for infection related to a decreased inflammatory response. 4. Risk for injury related to weakness and fatigue. 5. Disturbed thought processes related to mood swings and irritability.

618. Aclient is admitted to the hospital with a diag nosis of Cushing’s disease. A nurse reviews the client’s laboratory results. Which findings would sup port a diagnosis of Cushing’s syndrome? SELECT ALL THAT APPLY. 1. Hyperglycemia. 2. Eosinophilia. 3. Hypocalcemia. 4. Hypokalemia. 5. Thrombocytopenia. 6. Elevated serum plasma cortisol.

619. A nurse’s assessment of a client diagnosed with Cushing’s syndrome includes the following findings: 4+ pitting leg edema, blood glucose 140 mg/dL, irregular heart rate, and ecchymosis on the right arm. Which action should be taken by the nurse first?. 1. Weigh the client. 2. Administer insulin. 3. Notify the physician. 4. Measure the client’s abdominal girth.

620.A client diagnosed with Cushing’s syndrome is admitted with fluid volume overload. The client weighed 190 pounds on admission to the hospital. After treatment, the client weighs 179 pounds. The nurse estimated that the amount of fluid the client lost was _______ mL.

621. Which medication should a nurse plan to administer to a client admitted in Addisonian crisis?. 1. Regular insulin. 2. Ketoconazole (Nizoral®). 3. Sodium nitroprusside (Nipride®). 4. Hydrocortisone (Solu-Cortef®).

622.A nurse is caring for a client who is hospitalized with adrenocortical insufficiency. The nurse reviews the client’s serum laboratory values and immediately noti fies the physician. Which serum laboratory value most likely prompted the nurse to notify the physician?. 1. WBC 11.0 K/µL. 2. Glucose 138 mg/dL. 3. Sodium 148 mEq/L. 4. Potassium 6.2 mEq/L.

623.Which clinical change should indicate to a nurse that the therapy for a client with Addisonian crisis is effective?. 1. An increase of 25 mm Hg in the client’s systolic blood pressure. 2. A decrease of 25 mm Hg in the client’s systolic blood pressure. 3. An increase in the client’s serum potassium level from 3.4 to 4.8 mEq/dL. 4. An increase in the client’s total serum calcium level from 8.6 to 10.0 mg/dL.

624.What should be a nurse’s priority when admitting a client with suspected hyperaldosteronism?. 1. Preparing the client for a computed tomography (CT) scan. 2. Administering medications to treat headache. 3. Obtaining an electrocardiogram (ECG) to assess for cardiac dysrhythmias. 4. Protecting the client from falls due to muscle weakness.

625.A nurse is preparing to discharge a client following a unilateral adrenalectomy to treat hyperaldosteronism caused by an adenoma. Which instruction should be included in this client’s discharge teaching?. 1. Avoid foods high in potassium. 2. Self-monitor the blood pressure. 3. Discontinue medications taken prior to the adrenalectomy. 4. Carry an emergency kit that includes epinephrine.

626.A nurse is caring for a client who is experiencing symptoms associated with pheochromocytoma. Which intervention should be included in the care of this client?. 1. Offer distractions such as television or music. 2. Encourage frequent intake of oral fluids. 3. Assist with ambulation at least three times a day. 4. Administer nicardipine (Cardene®) to control hypertension.

627. A nurse is assigned to four clients who have been diagnosed with gastric ulcers. Which one of these clients should the nurse conclude is most at risk to develop gastrointestinal (GI) bleeding?. 1. A 40-year-old client who is positive for Helicobacter pylori (H. pylori). 2. A 45-year-old client who drinks 4 ounces of alcohol a day. 3. A 70-year-old client who takes aspirin (Ecotrin®) 81 mg daily to prevent coronary artery disease. 4. A 30-year-old pregnant client who uses acetaminophen (Tylenol®) as needed for headaches.

628.A nurse is assessing a client who is 24 hours postgas trointestinal (GI) hemorrhage. The assessment find ings include blood urea nitrogen (BUN) of 40 mg/dL and serum creatinine of 0.8 mg/dL. After reviewing the assessment findings, the nurse should: 1. immediately call the physician to report these results. 2. monitor urine output as this may be a sign of kidney failure. 3. document the findings and continue monitoring the client. 4. encourage the client to limit his dietary protein intake.

629.An experienced nurse explains to a new nurse that the definitive diagnosis of peptic ulcer disease (PUD) involves: 1. a urea breath test. 2. upper gastrointestinal endoscopy with biopsy. 3. barium contrast studies. 4. the string test.

630. During a hospital admission history, a nurse suspects gastrointestinal reflux disease (GERD) when the client says: 1. “I have been experiencing headaches immediately after eating.”. 2. “I have been waking up at night lately with a burning feeling in my chest.”. 3. “I have been waking up at night sweating.”. 4. “Immediately after eating I feel sleepy.”.

631. To assist a client to manage and decrease the sensation of nausea, which nonpharmacological inter vention should a nurse recommend?. 1. Drinking tea made from ginger root. 2. Changing positions quickly when moving. 3. Decreasing food intake. 4. Playing loud rock music.

632.A nurse, writing a nursing diagnosis in the care plan for a female client after bariatric surgery, should write, “Risk for nausea related to: 1. overfilling of the stomach pouch.”. 2. being female.”. 3. the lower half of the stomach becoming spastic.”. 4. handling of the duodenum with resulting inflammatory response.”.

633.A nurse is discharging a client after Billroth II surgery (gastrojejunostomy). To assist the client to control dumping syndrome, the client’s discharge instructions should include: 1. drinking fluids with meals. 2. eating a high-carbohydrate, low-protein diet. 3. waiting at least 5 hours between meals. 4. lying down for 20 to 30 minutes after meals.

634.After Billroth II surgery (gastrojejunostomy), a client experiences weakness, diaphoresis, anxiety, and palpations 2 hours after a high carbohydrate meal. A nurse should interpret that these symptoms indicate the development of: 1. steatorrhea. 2. duodenal reflux. 3. hypervolemic fluid overload. 4. postprandial hypoglycemia.

635.A nurse is performing an initial postoperative as sessment on a client following upper gastrointestinal surgery. The client has a nasogastric tube to low, intermittent suction. To best assess the client for the presence of bowel sounds, the nurse should: 1. place the stethoscope to the left of the umbilicus. 2. turn off the nasogastric suction. 3. use the bell of the stethoscope. 4. turn the suction on the nasogastric tube to continuous.

636.An experienced nurse is most likely to teach a new nurse that surgery to repair a hiatal hernia is becoming more common to prevent the emergency complication of: 1. severe dysphagia. 2. esophageal edema. 3. hernia strangulation. 4. aspiration.

637. A nurse, caring for a client with a Zenker’s diverticulum, knows that the priority nursing diagnosis for this client should be: 1. Pain related to gastric reflux. 2. Risk for aspiration related to regurgitation of food accumulated in the diverticula. 3. Constipation related to anatomical changes of the sigmoid colon. 4. Altered nutrition, less than body requirements related to dysphagia.

638.A client returns to a surgical unit following a radical neck dissection for oral cancer. The nursing plan of care for this client should include: 1. positioning the client in a supine position. 2. monitoring the wound drainage tubes around the neck incision for amount and color of drainage and patency. 3. maintaining bed rest for 48 hours postsurgery. 4. offering ice chips orally 2 hours postsurgery.

639.A nurse is caring for a client immediately after radical neck surgery. In which order should the nurse address the established nursing diagnoses? Prioritize the nurse’s actions by placing each diagnosis in the cor rect order. ______ Impaired swallowing related to tissue edema. ______ Risk for ineffective breathing pattern related to tissue edema. ______ Anxiety related to the surgical procedure. ______ Risk for infection related to altered tissue integrity.

640.A nurse is performing a health history on a client during a clinic visit. The client provides all of the following information. Which client statement should be most concerning to the nurse because it could be a symptom of esophageal cancer?. 1. “I have been having a lot of indigestion lately.”. 2. “When I eat meat it seems to get stuck halfway down.”. 3. “I have been waking up at night lately with chest pain.”. 4. “I have been gaining weight, even though I have not changed my diet.”.

641.Following an esophagectomy with colon interposition (esophagoenterostomy) for esophageal cancer, a client is beginning to eat oral foods. A nurse is con cerned about the risk of aspiration because the client no longer has a: 1. stomach. 2. pyloric sphincter. 3. pharynx. 4. lower esophageal sphincter.

642. During a health promotion seminar for senior citizens, a seminar participant asks a nurse to discuss symptoms of gastric cancer. A nurse’s response should be based on the knowledge that: 1. cancers that do not penetrate the gastric muscular layer are asymptomatic in the majority of clients. 2. pain from early gastric cancer lesions cannot be reduced by over-the-counter (OTC) histamine receptor antagonists. 3. unexplained weight gain and increased body mass index are early symptoms of gastric cancer. 4. anemia is uncommon in gastric cancer, but if it occurs it is likely due to the effects of aging.

643.A nurse has just received report on a 55-year-old client who had Billroth II surgery 24 hours ago. The client’s wife is listed as the designated contact person. Immediately after report, the client’s son approaches the nurse in the hallway and asks for information re garding his father’s condition. The nurse’s best re sponse would be: 1. “What has the surgeon told you about your father?”. 2. “Let’s go into your father’s room together and ask him how he feels.”. 3. “Let’s go to a more private place to discuss your father’s condition.”. 4. “Let’s review his medical record together.”.

644.A nurse is admitting a client with gastric cancer to an oncology unit for treatment. The nurse knows that the cancer has metastasized to the peritoneal cavity when which item of assessment data is collected?. 1. The client is reporting nausea. 2. A nurse observes Grey Turner’s sign. 3. The client is reporting rapid weight loss. 4. A nurse observes ascites.

645.A nurse is reviewing the health history of a client ad mitted to a hospital with a diagnosis of nonalcoholic fatty liver disease (NAFLD). When conducting the client’s health history, which finding is consistent with this disease process?. 1. 70 years old. 2. Obese. 3. History of recent antibiotic use. 4. Living in colder climates.

646.The serum ammonia level of a client with cirrhosis is elevated. As a priority, a nurse should plan to: 1. monitor the client’s temperature every 4 hours. 2. observe for increasing confusion. 3. measure the urine specific gravity. 4. restrict the client’s oral fluid intake.

647. A client is hospitalized for conservative treat ment of cirrhosis. As part of the collaborative plan of care, a nurse would anticipate: 1. monitoring the client’s blood sugar. 2. maintaining NPO (nothing by mouth) status. 3. administering antibiotics. 4. encouraging frequent ambulation.

648.While caring for a male client with cirrhosis, a nurse adds the nursing diagnosis Disturbed body image re lated to physical manifestations of illness when the client is overheard telling his brother: 1. “I don’t think I can handle this disease.”. 2. “I know the doctors say I have liver failure, but I don’t really believe them.”. 3. “I know I should rest more, but I’m just not that type of person.”. 4. “I don’t like the fact that I seem to have breasts now.”.

649.A client diagnosed with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement. A nurse realizes the client does not under stand the procedure when the client says: 1. “I hope my abdominal incision heals better after this procedure then it did when I had my appendix out.”. 2. “This procedure should decrease the risk that I might have another episode of bleeding from my esophagus.”. 3. “I know the shunt they are placing could become occluded in the future.”. 4. “This procedure should keep me from getting so much fluid buildup in my abdomen.”.

650.After completing discharge education, a nurse recog nizes the need for further teaching when a client, di agnosed with cirrhosis, says: 1. “I know propranolol (Inderal®) has been ordered to decrease my blood pressure.”. 2. “I plan to stop drinking alcohol.”. 3. “I am going to work only part-time.”. 4. “I know furosemide (Lasix®) will help to keep me from developing abdominal swelling.”.

651.A client preparing for a liver transplantation, asks a nurse to show him where his new liver will be lo cated. Which area should the nurse identify as the location of the client’s liver transplant?.

652.A nurse suspects that a client, admitted with upper right-sided abdominal pain, may have liver cancer when which serum laboratory test result is noted to be elevated?. 1. Creatinine. 2. Serum -fetoprotein (AFP) levels. 3. Serum phosphorus levels. 4. CA-125.

653. A client tells a nurse that she has been diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know what type of treatment should be anticipated. The nurse’s response should reflect the knowledge that: 1. chemotherapy is the first-line treatment for liver cancer. 2. because of the vascularity of the liver, it is not possible to excise the cancerous tumor using an open surgical approach. 3. liver transplantation is not an option for clients with liver cancer. 4. radiofrequency ablation has been successful in treating tumors of that size.

654.A registered nurse (RN) is caring for a client follow ing a liver biopsy with the assistance of a student nurse. The RN evaluates that the student understands the postprocedure care when the student nurse: 1. plans to monitor vital signs every hour. 2. promotes ambulation 1 hour after the procedure. 3. positions the client on the right side. 4. encourages the client to cough and deep breathe immediately following the procedure.

655. During a hospital admission history, a nurse suspects acute pancreatitis when a 40-year-old client reports: 1. the sudden onset of intense pain in the upper left abdominal quadrant that radiates to the back. 2. persistent abdominal pain in the lower abdomen that has shifted to the lower right quadrant. 3. bloody diarrhea and colicky abdominal pain. 4. mild upper abdominal pain and projectile vomiting.

656.While performing an assessment of a client with acute pancreatitis,a nurse notes the following skin appearance. What should be the nurse’s interpretation of this finding?. 1.Seepage of blood-stained exudates from the pancreas has occurred. 2.The pancreatitis has caused the stomach to bleed and the blood is now in the interstitial tissue. 3.An intestinal obstruction that has increased vascular pressure has developed due to the pancreatic inflammation. 4.Portal hypertension has developed.

657. Which activities should a nurse,caring for a client with acute necrotizing pancreatitis,implement as part of a collaborative plan of care for this client? SELECT ALL THAT APPLY. 1.Administering 1,000 mL intravenous (IV) fluid bolus over 1 hour followed by IV fluids at 250 mL/hour. 2.Initiating nasojejunal enteral feedings. 3.Administering IV imipenem-cilastatin (Primaxin®) 500 mg every 6 hours. 4.Ambulating four times daily. 5.Positioning on left side with head of bed elevated. 6.Inserting a Foley catheter.

658. A client recovering from acute pancreatitis that has been NPO (nothing per mouth) asks a nurse when he can begin eating again. Which response by the nurse is most accurate?. 1. “As soon as you start to feel hungry you can begin eating.”. 2. “When you have active bowel sounds and you are passing flatus.”. 3. “When your pain is controlled and your serum lipase level has decreased.”. 4. “Oral intake stimulates the pancreas so you will need to be NPO for at least 2 weeks from the day your disease was diagnosed to allow the pancreas to heal.”.

658. A client recovering from acute pancreatitis that has been NPO (nothing per mouth) asks a nurse when he can begin eating again. Which response by the nurse is most accurate?. 1. “As soon as you start to feel hungry you can begin eating.”. 2. “When you have active bowel sounds and you are passing flatus.”. 3. “When your pain is controlled and your serum lipase level has decreased.”. 4. “Oral intake stimulates the pancreas so you will need to be NPO for at least 2 weeks from the day your disease was diagnosed to allow the pancreas to heal.”.

659.A 40-year-old client is recovering from an exacerba tion of chronic pancreatitis. As the client prepares for discharge, the client makes several statements to a nurse. Which statement should be concerning to the nurse because it could inhibit the client’s ability to accomplish the developmental tasks of middle adulthood?. 1. “I’m planning on continuing to be active in the local town service club.”. 2. “I should be able to return to work in 3 weeks.”. 3. “I’ve really missed my friends. I’m looking forward to having a glass a wine with them.”. 4. “My spouse has been very supportive.”.

660.A client diagnosed with chronic pancreatitis, is con cerned about pain control. A nurse explains to the client that the initial plan for controlling the pain of chronic pancreatitis involves the administration of: 1. opioid analgesic medications. 2. NSAIDs. 3. pancreatic enzymes with H2 blocker medications. 4. acetaminophen (Tylenol®) and low-carbohydrate diet.

661.In preparation for providing care to a client imme diately after a Whipple procedure, a nurse should anticipate that the nursing care plan may include: 1. monitoring the blood glucose levels. 2. administering enteral feedings. 3. irrigating the nasogastric (NG) tube with 30 mL of saline every 4 hours. 4. assisting the client to the commode to promote bowel elimination within the first 8 hours postsurgery.

662.While reviewing a client’s medical records, a nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?. 1. Bloody diarrhea. 2. Heartburn and regurgitation. 3. Abdominal distention. 4. Severe abdominal pain.

663.A nurse anticipates that the conservative treatment of a client with acute cholecystitis will include: 1. a bland diet. 2. the administration of anticholinergic medications. 3. placing the client in a supine position with the head of the bed flat. 4. administering laxatives to clear the bowel.

664.A nurse is beginning client care and has been as signed to the following four clients. Which client should the nurse plan to assess first?. 1. A 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numeric scale. 2. A 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes. 3. A 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night. 4. A 54-year-old client with cirrhosis and jaundice who is reporting itching.

665.A nurse is caring for a client who is 6 hours post–open cholecystectomy. The client’s T-tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?. 1. Repositioning the client to promote T-tube drainage. 2. Notifying the surgeon about these findings. 3. Checking the client’s blood pressure immediately. 4. Recording the findings and continuing to monitor the client.

666.A Chinese client with diarrhea refuses to drink the prescribed oral hydration solution and insists on hav ing chicken broth instead. A nurse’s intervention in this situation should be based on the knowledge that Chinese clients: 1. know that chicken is a food with yang qualities. 2. believe foods high in sodium should be used to treat diarrhea. 3. believe extra protein is needed to treat diarrhea. 4. mistrust modern medicine and often use simple foods to treat disease.

667.During a hospital admission history, a nurse suspects irritable bowel syndrome (IBS) when the client says: 1. “I am having a lot of bloody diarrhea.”. 2. “I have been vomiting for 2 days.”. 3. “I have lost 10 pounds in the last month.”. 4. “I have noticed mucus in my stools.”.

668.A health-care provider writes the following admission orders for a client with possible appendicitis. Which order should the nurse question?. 1. Apply heat to abdomen to decrease pain. 2. Withhold analgesic medications to avoid masking critical changes in symptoms. 3. Keep client NPO (nothing per mouth). 4. Start lactated Ringer’s solution intravenously (IV) at 125 mL/hr.

669.A 22-year-old college senior has just been diagnosed with acute appendicitis requiring surgery. The client has been nauseated for 2 days, rates the pain as 4 out of 10 on a numeric scale, and tells the nurse, “I can’t believe this is happening. I have final exams starting in 3 days. What am I going to do?” A nurse develops the following preoperative diagnoses for this client. Which nursing diagnosis should be priority?. 1. Anxiety related to situational crisis. 2. Acute pain related to tissue injury. 3. Risk deficient fluid volume related to nausea. 4. Risk for delayed development related to illness and need for recovery.

670.A nurse is reviewing the history and physical of a teenager admitted to a hospital with a diagnosis of ulcerative colitis. Based on this diagnosis, which information should the nurse expect to see on this client’s medical record?. 1. Abdominal pain and bloody diarrhea. 2. Weight gain and elevated blood glucose. 3. Abdominal distension and hypoactive bowel sounds. 4. Heartburn and regurgitation.

671.A 20-year-old male client is admitted to a hospital with an exacerbation of ulcerative colitis. A female nurse goes into the client’s room to complete an ini tial assessment, and the client yells, “Get out of here! I’m tired of nurses and doctors looking at my body all the time!” Which is the nurse’s best action?. 1. Leave the room and ask a male colleague to complete the assessment. 2. Verbally acknowledge the client’s frustration and anger. 3. Call the health-care practitioner and ask for a sedative order. 4. Tell the client that gathering data about his current condition will promote effective timely treatment of his health concerns.

672.A 25-year-old client, admitted to the hospital with an exacerbation of ulcerative colitis, is placed on mesalamine (Asacol®), which is to be administered rectally via enema. The client finds this procedure distasteful and asks the nurse why the medication cannot be given orally. Which is the best response by the nurse?. 1. “It can be given orally; I’ll contact the doctor and see if the change can be made.”. 2. “Rectal administration delivers the medication directly to the affected area.”. 3. “Oral administration will not be as effective for the disease condition.”. 4. “It can be given orally, I’ll make the change and we’ll tell the doctor in the morning.”.

673.A 30-year-old client is 6 days post–total procto colectomy with ileostomy creation for ulcerative colitis. During morning report, a nurse is told that the ileostomy is draining large amounts of liquid stool and the client has been reporting dizziness with ambulation. Based on this information, which parameters should the nurse assess immediately? SELECT ALL THAT APPLY. 1. Pulse rate for the last 24 hours. 2. Urine output. 3. Weight over the last 3 days. 4. Ability to move the lower extremities. 5. Temperature readings for the last 24 hours.

674. A registered nurse (RN) overhears a licensed practi cal nurse (LPN) talking with a client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. To decrease the client’s anxiety, the RN should intervene to clar ify the information given by the LPN when the LPN is heard saying: 1. “this surgery will prevent you from developing colon cancer.”. 2. “after this surgery you will no longer have ulcerative colitis.”. 3. “when you return from surgery you will not be able to eat solid food for several days.”. 4. “you will have an ileostomy when you return from this surgery.”.

675.A nurse is caring for a client diagnosed with Crohn’s disease, who has undergone a barium enema that demonstrated the presence of strictures in the ileum. Based on this finding, the nurse should monitor the client closely for signs of: 1. peritonitis. 2. obstruction. 3. malabsorption. 4. fluid imbalance.

676. While discharging a 25-year-old female client after a small bowel resection for Crohn’s disease, a nurse overhears the client talking to her husband and real izes that the client needs more education when the client says: 1. “I’m so glad I won’t ever need any more surgeries.”. 2. “I’ll need to continue to monitor my weight.”. 3. “If I have another exacerbation I know they will probably put me back on hydrocortisone.”. 4. “I will probably have to take vitamin supplements all of my life.”.

677.A charge nurse on a medical unit is determining where on the unit to place a client who is being admitted with exacerbation of Crohn’s disease. The client is female, 20 years old, alert and oriented, and has been taking azathioprine (Imuran®) for disease control. Into which room should the nurse place the client?. 1. Private room right across from the nurses’ station to allow constant visualization. 2. Room with a 22-year-old female client who also has Crohn’s disease. 3. Private room with a private bathroom. 4. Room with an older adult female client who is oriented and on bedrest.

678.While conducting a home visit with a client who had a partial resection of the ileum for Crohn’s disease 4 weeks previously, a nurse becomes concerned when the client says: 1. “My stools float and seem to have fat in them.”. 2. “I have gained 5 pounds since I left the hospital.”. 3. “I am still avoiding milk products.”. 4. “I only have two formed stools per day.”.

679.A nurse is assessing a client, with a diagnosed in guinal hernia, at a scheduled clinic visit. The nurse suspects that the client’s hernia may be strangulated when which finding is noted on assessment?. 1. Shortness of breath. 2. Intense abdominal pain. 3. Constipation. 4. Hyperactive bowel sounds.

680.A nurse is reviewing the health history of a client be ing evaluated for treatment of hemorrhoids. Which information related to the development of hemor rhoids should the nurse expect to find in the client’s medical history?. 1. Body mass index (BMI) of 18. 2. Chronic constipation. 3. Nulliparous. 4. Occupation: Salesperson.

681.A client is being admitted to a postsurgical unit follow ing anorectal surgery. A nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?. 1. Administer morphine sulfate per intravenous bolus before the first defecation. 2. Administer sitz bath after each defecation. 3. Begin high-fiber diet as soon as client can tolerate oral intake. 4. Position client in supine position with the head of the bed elevated to 30 degrees.

682.A client is admitted to a hospital for medical treat ment of acute diverticulitis. A nurse should anticipate that this client’s treatment plan will include: SELECT ALL THAT APPLY. 1. NPO (nothing per mouth) status. 2. frequent ambulation. 3. antibiotics. 4. antiemetic medication. 5. deep breathing every 2 hours.

683. A nurse is assessing a client diagnosed with acute diverticulitis. Which finding should make the nurse suspect that the client has an intestinal perfo ration?. 1. Elevated white blood cells (WBCs). 2. Temperature of 101°F (38.3°C). 3. Absent bowel sounds. 4. Abdominal pain.

684.A family member tells a nurse that her father, who was told 24 hours ago that he has terminal colon can cer, refuses to see the family priest. He has also asked that his phone be disconnected so that he does not need to interact with other family members and friends. He told his daughter that he has decided he was never going to pray again in spite of the fact that previously he has been a very religious person. Based on this information, which nursing diagnosis should the nurse develop for this client?. 1. Decisional conflict about how to manage his cancer diagnosis related to lack of experience with terminal illness. 2. Risk for spiritual distress related to diagnosis of terminal cancer. 3. Spiritual distress related to anxiety about the diagnosis of terminal cancer. 4. Noncompliance related to spiritual values.

685.After examining a client’s laboratory results, a nurse suspects that a client’s colon cancer has metastasized to the liver. Which laboratory values should lead the nurse to make this conclusion?. 1. Elevated aspartate aminotransferase (AST) and alkaline phosphatase (ALP). 2. Elevated BUN (blood urea nitrogen) and Cr (creatinine). 3. Decreased albumin and calcium. 4. Elevated WBCs (white blood cells) and neutrophils.

686. A nurse is caring for a client who had surgery for colon cancer, which included the creation of a temporary colostomy. The client is 24 hours postsurgery. During an assessment of the client, a nurse notes no stool in the colostomy bag. A review of the client’s medical records indicates that, since surgery, there has not been stool in the bag. Considering this information, the nurse should: 1. call the doctor immediately to report this finding. 2. reposition the client to the left side. 3. document the findings. 4. administer pain medication.

687. A client, who had a sigmoid colectomy for colon cancer is instructed at a follow-up clinic visit to take 325 mg of aspirin (Ecotrin®) per day. A nurse explains to the client that the aspirin will: 1. decrease the surgical pain. 2. promote healing of the surgical incision. 3. prevent the return of cancer in the colon. 4. prevent metastasis of the cancer to other areas of the body.

688.While caring for a surgical client during the first 24 hours after an abdominal–perineal resection, a nurse should give the highest priority to: 1. providing a low-residue diet. 2. monitoring the amount and color of stool in the colostomy bag. 3. assessing perineal dressings and drainage. 4. encouraging observation and acceptance of the colostomy site.

689. A nurse is conducting a home visit with a client who had surgery 3 months ago that involved the cre ation of a colostomy. When the nurse arrives at the home, the client’s wife reports that her husband has lost interest in golf, which used to be his passion. She also says he cries often for no reason, is only able to sleep for a few hours each night, and reports fatigue daily. The wife asks the nurse for advice. A nurse’s response should be based on the knowledge that: 1. twenty-five percent of all clients develop clinically significant depression after ostomy surgery. 2. athletic activities like golf are not possible after ostomy surgery. 3. after 3 months the client should have accepted his new body image. 4. it is difficult to sleep well with an ostomy.

690.For a client with a newly created colostomy, a nurse creates this diagnosis: risk for sexual dysfunction re lated to body image change. To promote satisfying sexual functioning after ostomy surgery, which rec ommendation should the nurse make to the client?. 1. Participate in sexual activity only in a darkened room. 2. Utilize self-gratification for the majority of sexual needs. 3. Empty and clean the ostomy pouch immediately before sexual activity. 4. Utilize only the female superior position for sexual activity.

691.A nurse anticipates that the care of a client newly ad mitted to a medical unit with a diagnosis of peritoni tis should include: SELECT ALL THAT APPLY. 1. intravenous (IV) fluids. 2. antibiotics. 3. NPO (nothing per mouth) status. 4. analgesic therapy. 5. positioning in a supine position. 6. nasogastric (NG) tube to suction.

692.A nurse is preparing a client for a bone marrow biopsy of the iliac crest. Which actions should be taken by the nurse when preparing the client? Priori tize the nurse’s actions by placing each step in the correct order. ______ Premedicate with lorazepam (Ativan®). ______ Obtain a signed informed consent. ______ Position the client in a prone position. ______ Verify that the physician has explained the procedure. ______ Check for signs of bleeding every 2 hours for 24 hours. ______ Support the client by holding the client’s hand or using guided imagery. ______ Support the client by holding the client’s hand or using guided imagery.

693.A homeless client, visiting a health clinic, is noted to have a smooth and reddened tongue and ulcers at the corners of the mouth. The client was tentatively diag nosed with a hematological disorder, and laboratory tests were prescribed. Based on this information, a nurse should expect the client’s laboratory results to reveal: 1. low hemoglobin. 2. elevated red blood cells (RBCs). 3. prolonged prothrombin time (PT). 4. low white blood cells (WBCs).

695.A nurse should assess a client with hemolytic anemia for weakness,fatigue,malaise,skin and mucous membrane pallor,and: 1.jaundice. 2.a smooth red tongue. 3.a craving for ice. 4.a poor intake of fresh vegetables.

696.A nurse is caring for multiple 25-year-old female clients. For which clients should the nurse plan to ob tain a referral for genetic counseling and family plan ning? SELECT ALL THAT APPLY. 1.Client diagnosed with thalassemia major. 2.Client diagnosed with sickle cell disease. 3.Client diagnosed with hemophilia A. 4.Client diagnosed with autoimmune hemolytic anemia. 5.Client diagnosed with hemophilia B.

697.A client is hospitalized with a diagnosis of sickle cell crisis. Which findings should lead a nurse to con clude that outcomes have been achieved for this client? SELECT ALL THAT APPLY. 1.Leukocyte count 7,500/mm3. 2.Describes the importance of keeping warm. 3.Acute pain controlled at less than 3 on a 0 to 10 scale with analgesics. 4.Free of chest pain or dyspnea. 5.Blood transfusions effective in diminishing cell sickling. 6.Hydroxyurea (Hydrea®) effective in suppressing leukocyte formation.

698.A client with a diagnosis of chronic obstructive pul monary disease (COPD) has developed polycythemia vera,and a nurse has completed teaching on meas ures to prevent complications. During a home health visit, the nurse evaluates that the client is correctly following the teaching when the client:SELECT ALL THAT APPLY. 1.tells the nurse about discontinuing iron supplements. 2.relays increasing alcohol intake to decrease blood viscosity. 3.records the amount consumed after drinking a glass of water. 4.discusses yesterday’s phlebotomy treatment to remove blood. 5.shows the nurse a menu plan for eating three large meals daily. 6.reclines in a recliner chair with legs uncrossed, wearing antiembolic stockings (TEDS®).

699.A nurse explains to another nurse that chronic lym phocytic leukemia (CLL) is:SELECT ALL THAT APPLY. 1.a malignancy of activated B lymphocytes. 2.the most common malignancy of older adults. 3.unresponsive to chemotherapy treatment. 4.often not treated in its early stages but the client is monitored. 5.an excessive accumulation of immature lymphocytes in the bone marrow. 6.often asymptomatic and diagnosed incidentally during routine physical examination.

700. A client is neutropenic following treatment for acute lymphocytic leukemia and is now experiencing hypotension, tachycardia,and an elevated tempera ture. Because an infection is suspected,a nurse noti fies a physician. Which physician order should be the nurse’s priority?. 1.Portable chest x-ray. 2.Urine and blood cultures. 3.Vancomycin (Vancocin®) 1 gm intravenously (IV) every 12 hours. 4.Filgrastim (Neupogen®) 10 mg/kg subcutaneously daily.

701. A nurse is analyzing the serum laboratory re port below for a client with a diagnosis of acute myeloid leukemia. Based on the findings of the serum laboratory report,which nursing action is most appropriate?. 1.Instruct the client on foods to eat that are high in iron. 2.Assess the client for an allergic reaction. 3.Place the client on neutropenic precautions. 4.Teach the client to use an electric razor when shaving.

702.A nurse obtains the following assessment data for a client diagnosed with acute myeloid leukemia. For which finding should a nurse plan interventions first?. 1. Pain from mucositis. 2. Weakness and fatigue. 3. T 99°, P100, R 20, and BP 132/64 mm Hg. 4. Ecchymosis and petechiae noted on arms.

703.A client who is receiving doxorubicin (Adriamycin®) for the first time to treat multiple myeloma develops flushing, facial swelling, headache, chills, and back pain. Which statement made by the nurse is best?. 1. “These symptoms are uncomfortable for you, and I can give more medication for symptom control; these usually resolve in 1 day and are limited to the first dose.”. 2. “These symptoms are concerning. You may want to consider terminating treatment because these are signs of unacceptable toxicity.”. 3. “Next time you can receive premedication with ondansetron (Zofran®), an antiemetic to prevent these symptoms.”. 4. “Side effects will occur with chemotherapy. Focus on the goal of curing your cancer, and then the side effects will be more tolerable.”.

704.Following a shift report on an oncology unit, a nurse determines that which client should be assessed first?. 1. A client with breast cancer who has an order for ondansetron (Zofran®) 8 mg intravenously (IV) 30 minutes prior to chemotherapy. 2. A client just admitted with a temperature of 101°F (38.3°C), diaphoresis, and an absolute neutrophil count of 98/mm3. 3. A client with breast cancer who is scheduled for external beam radiation in 15 minutes. 4. A client with stomatitis associated with tonsilar cancer who receives gastrostomy tube feedings.

705.A clinic nurse is planning to assess the lymph nodes for a client with suspected Hodgkin’s lymphoma, starting at the location where the disease usually be gins. On the illustration below,at which area should the nurse plan to begin the examination?. 1.A. 2.B. 3.C. 4.D.

706.A female client is to receive chemotherapy and radia tion for Hodgkin’s lymphoma with cervical and axil lary node involvement. A nurse evaluates that the client is coping positively when the client states: 1.“I selected a wig that matches my hair color,but I will miss my own hair.”. 2.“I am so glad that the chemotherapy and radiation treatments won’t cause me to lose my hair.”. 3.“The chemotherapy-drug combination will prevent mucositis and immunosuppression.”. 4.“I have faith that my doctor will be able to cure me and I won’t have any long-term effects.”.

707.A physician documents that a client, diagnosed with stage III non-Hodgkin’s lymphoma (NHL), is experi encing “B symptoms.” A nurse interprets this to mean that the client has: 1. bleeding associated with low platelets counts. 2. a B lymphocyte malignancy and has progressed to an untreatable stage. 3. symptoms from exposure to a viral infection, such as Epstein-Barr virus. 4. recurrent fever, drenching night sweats, and an unintentional weight loss of 10% or more.

708.A nurse is caring for a client hospitalized with idio pathic thrombocytopenic purpura (ITP). Which self care measures should the nurse plan to include when teaching the client? SELECT ALL THAT APPLY. 1. “Use dental floss after brushing your teeth to prevent gum hyperplasia.”. 2. “Use only an electric razor when shaving.”. 3. “Remove throw rugs in your home, and avoid clutter.”. 4. “Increase fiber in your diet, and drink plenty of liquids to avoid constipation.”. 5. “Keep appointments for monthly platelet transfusions.”.

709.A nurse teaches a coworker that the treatment for hemophilia will likely include periodic self administration of: 1. platelets. 2. whole blood. 3. factor concentrates. 4. fresh frozen plasma.

710. A client diagnosed with von Willebrand’s disease calls a clinic after experiencing hemarthrosis. Which treatment should a nurse recommend?. 1. “Treat the pain with two 325-mg aspirin (Ecotrin®) tablets every 4 hours.”. 2. “Apply cold packs 2 hours on and 2 hours off of the affected site for 24 to 48 hours.”. 3. “Come to the clinic immediately so you can receive an infusion of fresh frozen plasma.”. 4. “If you are wearing a splint, remove it immediately to avoid compartment syndrome.”.

711. A client has a wound suction device for blood sal vage following a left total knee replacement so that the blood can be reinfused into the client within the first 6 hours postoperatively. Which intervention should a nurse plan to implement to care for this wound suction device?. 1. Discard the first 500 mL in the suction container and wait until the container is full again before beginning a reinfusion. 2. As soon as the prescribed amount is noted in the container, obtain the blood and prepare it for reinfusion into the client intravenously. 3. Separate the blood from the drainage, and reinfuse the blood back through the drainage system into the wound. 4. Remove the blood from the drainage system and send it to the blood bank to be prepared for an infusion.

712.The family of a client who is scheduled for emer gency surgery following an accident asks if they can donate blood for the client. The client’s blood type is B negative. A nurse informs the family that packed red blood cells (PRBCs) could likely be used from family members whose blood type is: 1. type A positive. 2. type B positive. 3. type B negative. 4. type O positive. 5. type O negative. 6. type AB positive.

713.A nurse working in the blood mobile is screening clients to determine if they qualify for blood donation of whole blood. Which questions should the nurse ask during the screening interview? SELECT ALL THAT APPLY. 1.“What is your age?”. 2.“If you have a tattoo,when did you receive it?”. 3.“Have you had any close contact with anyone with HIV or hepatitis?”. 4.“If you smoke,when was the last time you smoked tobacco products?”. 5.“Have you been immunized for rubella,mumps,or varicella within the last month?”. 6.“Did you receive a blood transfusion or blood product anywhere outside of the United States?”.

714. A client with symptoms of anemia and a hemo globin of 7.8 g/dL refuses blood and blood products transfusions for religious reasons. A nurse should anticipate that a health-care provider might prescribe: SELECT ALL THAT APPLY. 1.Epoetin alfa (Procrit®). 2.Folic acid. 3.Albumin. 4.Platelets. 5.Fresh frozen plasma. 6.Granulocytes.

715. A client who has received 50 mL of a unit of whole blood complains of low back pain. In response to this client’s symptom, a nurse should first: 1. reposition the client. 2. assess the pain further. 3. administer an analgesic. 4. stop the blood transfusion.

716. At 1000 hours, a nurse is documenting after adminis tering 275 mL of compatible platelets, unit number XR123, to a client. Which information should the nurse document? SELECT ALL THAT APPLY. 1. “One unit blood infused over 4 hours.”. 2. “Platelet number XR123 checked prior to administration.”. 3. “No transfusion reactions noted.”. 4. “D5W infused with platelets to prevent cell clumping.”. 5. “Infusion of 275 mL of platelets started at 0830 hours completed.”.

717. A young adult with a diagnosis of hemophilia A is receiving a monthly scheduled dose of factor VIII cryoprecipitate (Bioclate®). While a nurse is adminis tering the Bioclate®, the client begins to cry. Which nursing response would be most appropriate?. 1. “Why are you crying? You seem afraid when I am administering the Bioclate®.”. 2. “Is it painful when I administer the Bioclate® intravenous push? If it is, I can administer it by infusion.”. 3. “I know this is uncomfortable for you, but this will only take about 3 minutes to administer.”. 4. “If you want to talk to me about what you are feeling, I am here to listen.”.

718. A client with leukemia asks a nurse to explain how donor cells are obtained for peripheral blood stem cell transplantation (PBSCT). Which statement by the nurse is correct?. 1. “A large amount of bone marrow tissue is harvested from a donor’s hip bone under general anesthesia in the operating room.”. 2. “Stem cells are collected from the donor’s blood, which goes through a machine, removes the stem cells, and then returns the blood back to the donor.”. 3. “Stem cells are collected from a donor through a process called apheresis, which removes the stem cells from the blood. This typically takes 10 to 15 minutes.”. 4. “Stem cells are obtained similar to other blood donations, where the blood is collected and then administered to you immediately following collection.”.

719. A female nurse tells a coworker that she is confused because a physician stated that graft-versus-host dis ease (GVHD) symptoms were desirable for a particu lar client after a bone marrow transplant. In which type of malignancy is GVHD sometimes desirable?. 1. Gastrointestinal. 2. Reproductive. 3. Neurological. 4. Hematological.

720. A client diagnosed with acute myeloid leukemia receives a bone marrow transplant. Which medication to prevent graft-versus-host disease (GVHD) should a nurse anticipate receiving an order to administer?. 1. A cephalosporin antibiotic, such as ceftazidime (Fortaz®). 2. An immunosuppressant, such as cyclosporine (Neoral®). 3. A chemotherapeutic agent, such as cisplatin (Platinol A-Q®). 4. Peginterferon alfa-2a (Pegasys®) for prevention and treatment of hepatitis.

721. A nurse is evaluating a client’s understanding of teaching about changes to expect following a bone marrow transplant (BMT). Which statement by the client indicates the client misunderstood the expected changes?. 1. “You can have weight gain from the side effects of your steroid immunosuppressant medications.”. 2. “Sterility can occur from the destruction of your own stem cells with chemotherapy and radiation.”. 3. “Cataracts may develop after total body irradiation.”. 4. “Changes to the mouth include a white, patchy tongue.”.

722.Which nursing diagnosis should have the highest pri ority for a client experiencing superior vena cava syn drome secondary to lung cancer?. 1. Ineffective breathing pattern. 2. Ineffective tissue perfusion. 3. Risk for infection. 4. Impaired skin integrity.

723.A nurse explains “watchful waiting” (ongoing visits to a physician for observation of signs and symptoms without treatment) to a client with prostate cancer. Under which circumstance should the nurse recom mend “watchful waiting”?. 1. When bone cancer is diagnosed along with prostate cancer. 2. When the client is older than age 70 with a life expectancy of less than 10 years with low-grade disease. 3. When a client has extension of the tumor outside of the prostate. 4. When a client has an elevated prostate specific antigen, has no symptoms, and is under the age of 60.

724.A nurse is teaching a client about self-breast exami nation and discusses where breast cancer commonly occurs. Identify with an X the area where the nurse should teach the client that breast cancer occurs most frequently.

725.Which actions should a nurse initiate for a client who had a left modified radical mastectomy (a total mastectomy with axillary node dissection and removal of the lining over the pectoralis major muscle)?. 1.Elevate the left arm above the head. 2.Insert all intravenous (IV) access sites on the right side. 3.Have the client view the incision site as soon as possible. 4.Initiate strengthening exercises of the left arm within 24 hours of surgery.

726.A nurse discusses the self-care guidelines to mini mize the side effects of radiation on the skin. Which actions, to reduce radiation skin reactions,should the nurse explain to the client? SELECT ALL THAT APPLY. 1.Wear loose-fitting,soft clothing over the treated skin. 2.Use a straightedged razor to shave the hair in the treated area. 3.Swim only in swimming pools to avoid stagnant water. 4.Use only skin-care products suggested by the radiation staff. 5.Apply skin products immediately before radiation treatment. 6.Wash treated area gently with lukewarm water and mild soap.

727.In discussing prevention of bladder cancer with a client,which factors that increase the client’s risk for bladder cancer should the nurse emphasize? SELECT ALL THAT APPLY. 1.Consuming caffein. 2.Smoking tobacco. 3.Consuming multivitamins. 4.Being exposed to paint smells. 5.Being exposed to the smell of tires in the rubber industry.

728.A client diagnosed with Hodgkin’s lymphoma devel ops radiation pneumonitis 3 months after radiation treatment. For which symptoms of radiation pneu monitis should a nurse observe the client?. 1. Tachypnea, hypotension, and fever. 2. Cough, fever, and dyspnea. 3. Bradypnea, cough, and decreased urine output. 4. Cough, tachycardia, and altered mental status.

729. Which nursing actions should a nurse imple ment to prevent extravasation when administering vesicant chemotherapy medications such as doxoru bicin hydrochloride (Adriamycin®)? SELECT ALL THAT APPLY. 1. Administer vesicant infusions through a peripheral intravenous (IV) device if it is to be infused in less than 60 minutes and check patency every 5 to 10 minutes. 2. Ask the client frequently about discomfort at the peripheral IV site during infusion. 3. Check the IV pump and alarm for indications of infiltration of the medication. 4. Check for blood return in a central venous catheter prior to administration of the vesicant medication. 5. Flush the peripheral and central venous catheters with 5 to 10 mL of normal saline between medications. 6. Use small-gauged syringes to flush all catheters.

730.A nurse cares for a client receiving combination chemotherapy of oxaliplatin (Eloxatin®), fluorouracil (5-FU), and leucovorin (Wellcovorin®). For which common side effects of this chemotherapy should the nurse assess the client?. 1. Neurotoxicities and diarrhea. 2. Cardiomyopathy and dysphagia. 3. Renal insufficiency and gastritis. 4. Photophobia and stomatitis.

731.A nurse assesses that a client, who is receiving radia tion for cervical cancer, continues to have diarrhea. Which nursing advice is most appropriate for this client?. 1. Take sitz baths twice daily and eat a low-residue diet. 2. Drink fluids low in potassium and take frequent tub baths. 3. Increase your intake of milk products and take frequent showers. 4. Drink fluids high in sodium and apply hydrocolloid dressings to reddened areas.

732.When assessing a client who is recovering from a radical hysterectomy with vulvectomy, a nurse notes lymphedema of the lower extremities. Which inter vention should be implemented by the nurse?. 1. Elevate the head of the bed to a 45-degree angle. 2. Increase the client’s intake of fluids high in sodium. 3. Encourage the client to exercise the lower extremities. 4. Apply lower-extremity splints.

733.A nurse is collecting data from a client with a sus pected diagnosis of basal cell carcinoma (BCC). Which risk factors in the client’s health history, iden tified by the nurse, support this diagnosis? SELECT ALL THAT APPLY. 1. Family history of BCC. 2. Frequent use of indoor tanning devices (beds or lamps with artificial light). 3. Smoking history. 4. Occupational exposure to carcinogens. 5. Exposure to indoor radon gas. 6. Works as a laborer in road construction.

734.A client phones a nurse after having three basal cell carcinoma (BCC) lesions excised the day before and is concerned that the wounds are draining a small amount of serosanguineous fluid and that the small dressing is leaking. Which action should the nurse recommend?. 1. Apply ice to the area. 2. Contact the physician. 3. Take medication for pain. 4. Change the dressings.

735.A client presents with a meningioma and symptoms of increased intracranial pressure. Which manifesta tions should a nurse least expect to find on assessment of this client?. 1. Headache. 2. Vomiting. 3. Pyrexia. 4. Papilledema.

736.When caring for a client with epigastric pain and sus pected gastric cancer, which diagnostic test should a nurse address with the client because it is the specific test used to diagnose the cancer?. 1. Arthroscopy. 2. Bronchoscopy. 3. Colonoscopy. 4. Esophagogastroduodenoscopy.

737.Which nursing diagnosis should a nurse plan to docu ment for the client with gastric cancer experiencing hematemesis?. 1. Impaired oral mucous membrane. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Fluid volume deficit.

738.A client diagnosed with esophageal cancer is having work-related problems. Which organization should a nurse advise the client to contact for assistance with these issues?. 1. National Cancer Institute. 2. Leukemia Society of America. 3. Corporate Angel Network. 4. Patient Advocate Foundation.

739.When caring for a client following a total laryngec tomy, with which members of the multidisciplinary team should a nurse plan consultations? SELECT ALL THAT APPLY. 1. Physical therapist. 2. Dietitian. 3. Speech therapist. 4. Dentist. 5. Occupational therapist. 6. Social worker.

740. A nurse assesses a client who has undergone a total laryngectomy. Which assessment findings should the nurse address first when caring for this client? Priori tize the nurse’s actions by placing the nurse’s find ings on a scale of 1 to 4 in order of priority: 1 being the item requiring immediate attention by the nurse and 4 being the item requiring last consideration. _____ Copious oral secretions and nasal mucus draining from the nose. _____ Restless and has a mucus plug in the tracheostomy. _____ Nasal gastric tube pulled halfway out and tube feeding continuing to infuse. _____ Oozing serosanguineous drainage around the tracheostomy tube and dressing saturated.

741. Which vaccine should a nurse recommend for prevention of liver cancer?. 1. Varicella vaccine. 2. Hepatitis A vaccine. 3. Meningococcal vaccine. 4. Hepatitis B vaccine.

742. A nurse is caring for a client diagnosed with hepato cellular carcinoma who is exhibiting a paraneoplastic syndrome. For which signs should the nurse assess?. 1. Erythrocytosis and hypercalcemia. 2. Hyperkalemia and hyperalbuminemia. 3. Hypernatremia and hypomagnesemia. 4. Hypocalcemia and hyperleukocytosis.

743. In the assessment of a client for endometrial cancer, a nurse would most likely find which symptoms at di agnosis of the disease?. 1. Abnormal vaginal bleeding and pain in the pelvic region. 2. Weight loss and profuse sweating. 3. Anorexia and enlarged supraclavicular lymph node. 4. Unexplained fevers and splenomegaly.

744. In discussing bad news with a client about a diagno sis of cancer, which actions are most appropriate for a nurse to use at this time of emotional impact? SELECT ALL THAT APPLY. 1. Advocate expression of feelings. 2. Avoid using the word cancer. 3. Give the client as much information as possible. 4. Maintain a professional detachment. 5. Promote a broad time frame by avoiding a definite time scale. 6. Provide for privacy and adequate time with family present.

745. A nurse counsels a family member of a cancer client about the caregiving role. Which self-care activity would help the family member cope with the care giver role?. 1. Being open to technologies and ideas that promote a loved one’s dependence. 2. Trusting that you are doing the right thing and staying focused on your loved one. 3. Grieving over losing personal time for self or care of other family members. 4. Self-education about a loved one’s condition and how to communicate effectively with health-care providers.

745. A nurse counsels a family member of a cancer client about the caregiving role. Which self-care activity would help the family member cope with the care giver role?. 1. Being open to technologies and ideas that promote a loved one’s dependence. 2. Trusting that you are doing the right thing and staying focused on your loved one. 3. Grieving over losing personal time for self or care of other family members. 4. Self-education about a loved one’s condition and how to communicate effectively with health-care providers.

746. A nurse is counseling the family of a client who died from terminal cancer. Which interventions are effec tive in assisting the family through the grief process? SELECT ALL THAT APPLY. 1. Listening actively without judgment. 2. Advising the family member to make change quickly to hasten the grieving process. 3. Encouraging time with the body of the deceased at the time of death. 4. Listening passively with minimal feedback to the family member. 5. Advising the family member to move on with life and place no meaning on the death. 6. Assisting the family member in further identifying the meaning of the loss in practical terms.

747. In discussing conditions important to the client at the terminal stages of cancer, which attributes should a nurse acknowledge as being important to the client at the end of life? SELECT ALL THAT APPLY. 1. Maintaining one’s dignity. 2. Being mentally sedated. 3. Maintaining a sense of humor. 4. Resolving unfinished business with family. 5. Having others plan funeral arrangements. 6. Saying goodbye to important people.

748. For a client experiencing severe cancer pain (pain intensity of 7 to 10 on a scale of 0 to 10, where 0 equals no pain and 10 equals the worst pos sible pain), which medication should a nurse plan to administer?. 1. Meperidine (Demerol®). 2. Propoxyphene (Darvon®). 3. Pentazocine (Talwin®). 4. Oxycodone (Oxycontin®).

749. A nurse is caring for a client who is experiencing pain related to cancer treatment. The client tells the nurse, “Methadone (Dolophine®) has always worked well for me in the past.” Which effects of methadone should the nurse consider before obtaining an order for the medication?. 1. Long half-life and high potency. 2. Central nervous system toxicity and potential to cause confusion. 3. Frequent allergic reactions and therapeutic doses causing liver failure. 4. Coagulation toxicity and short half-life.

750.A cancer client is requesting nonpharmacological in terventions for pain. Which research-supported inter ventions should the nurse implement to ease this client’s pain? SELECT ALL THAT APPLY. 1. Acupuncture. 2. Prayer. 3. Dance therapy. 4. Foot bracing. 5. House cleaning. 6. Music therapy.

751. A client with cancer pain may require treatment with coanalgesics or adjuvant medications to control pain. Which adjuvant medication gives the best response when given with opioids?. 1. Promethazine (Phenergan®). 2. Gabapentin (Neurontin®). 3. Diphenhydramine (Benadryl®). 4. Droperidol (Inapsine®).

752.A nurse is assessing the fluid status of a client with a second-degree burn who weighs 60 kg. The client is 5 hours postburn. The nurse determines that the client’s fluid status is inadequate and immediately notifies a physician when the client exhibits: 1. blood pressure 92/60 mm Hg and pulse rate 100 beats per minute (bpm). 2. respiratory rate 18 breaths per minute and pulse rate 60 bpm. 3. pulse rate 130 bpm and urine output 25 mL/hr. 4. pulse rate 106 bpm and temperature 98.4°F (36.9°C).

753.In planning the care for a client recovering from second- or third-degree burns, which psychosocial nursing diagnosis should have the highest priority?. 1. Disturbed sensory perception. 2. Disturbed thought processes. 3. Disturbed body image. 4. Disturbed personal identity.

754.Which medication should a nurse apply topically in second- and third-degree burns to treat bacterial and yeast infections?. 1. Bismuth subsalicylate (Kaopectate®). 2. Gold sodium thiomalate (Aurolate®). 3. Silver sulfadiazine (Silvadene®). 4. Arsenic trioxide (Trisenox®).

755. Which interventions should a nurse implement to assist a client with problems of anxiety and confu sion in the critical phases of burn injury? SELECT ALL THAT APPLY. 1.Repeat statements of orientation to person,place, and time with the client. 2.Turn the client every 2 hours for reorientation. 3.Place familiar objects brought from home nearby so the client can touch them. 4.Implement a schedule for regular sleep/wake cycles. 5.Keep the door of the room closed so that distractions can be controlled. 6.Encourage the client to write notes to family members.

756.A nurse is caring for a client with a large,open sternal wound resulting from a burn injury. The client is receiving enteral feeding,Oxepa®(an anti inflammatory,pulmonary 1.5 Cal/mL formula),at 25 mL/hour. Which abnormal laboratory value, reported in the exhibit below, indicates that the client is receiving inadequate nutrition?. 1.Phosphorus. 2.Platelets. 3.Pre-albumin. 4.Potassium.

757.A nurse is assessing a client following a skin graft. The nurse should suspect infection in the grafted wound when observing that the client has: 1.a white blood cell count (WBC) of 9.9 K/µL. 2.serosanguineous drainage. 3.elevated temperature. 4.decreased urine output.

758. A nurse cares for a client with a venous leg ulcer who undergoes trilayer artificial skin grafting. The nurse understands that grafted skin heals best on venous leg ulcers when which intervention is imple mented after grafting?. 1. Applying a gauze dressing. 2. Applying compression bandages. 3. Applying Xeroform® dressing. 4. Applying petrolatum bandages.

759. A nurse is explaining facelift (rhytidectomy) sur gery to a client. Place an X on the site where the inci sion most commonly used for rhytidectomy is made.

760. Which home measures should a nurse discuss with a client who is diagnosed with a carbuncle? SELECT ALL THAT APPLY. 1. Leave the draining lesion open to the air. 2. Employ strict hand washing to prevent cross contamination. 3. Cover mattress and pillows with plastic covers. 4. Apply ice to the affected area. 5. Wash all linens, towels, and clothing after each use. 6. Remove all throw rugs in the home.

761. During a physical assessment examination of the eyes, a nurse covers a client’s right eye and then ob serves a shift in the client’s gaze after the eye is un covered. This finding suggests: 1. opacity of the lens. 2. absence of the blink reflex. 3. weakness in the extraocular muscles. 4. increased intraocular pressure.

762. A nurse telephones a client who underwent cataract surgery the preceding day to assess the client’s condition. Which client statement necessitates an evaluation by an ophthalmologist?. 1. “My eye begins to hurt again about 4 hours after I take the pain pills the doctor ordered.”. 2. “The redness in my eye is much less than yesterday.”. 3. “I cannot see nearly as well as I could yesterday after the surgery.”. 4. “There is no swelling around my eye to speak of.”.

763. A client’s eyes are tested with the use of a Snellen chart. The assessment is documented as 20/40 in the right eye and 20/30 in the left eye. How should a nurse interpret these results? SELECT ALL THAT APPLY. 1. The client has elevated intraocular pressure in both eyes. 2. The client needs eye pressure readings performed with a tonometer to determine if the client has glaucoma. 3. The vision in the left eye is closer to normal vision than the vision in the right eye. 4. The client has presbyopia. 5. The client has errors of refraction in both eyes consistent with myopia.

764. A nurse speaks with a client who recently learned he has beginning cataracts in both eyes. Which statement made by the client should a nurse correct?. 1. “It is important that I have surgery done as soon as possible to prevent permanent damage to my vision.”. 2. “Cataracts are corrected by surgery, with each eye done at different times.”. 3. “The surgical treatment of a cataract involves the removal of the client’s own lens from the eye.”. 4. “An intraocular lens is placed in the eye at the time of surgery.”.

765. A family member of a client undergoing cataract surgery asks a nurse if there are ways to prevent cataracts. Which interventions decrease the risk for the development of cataracts? SELECT ALL THAT APPLY. 1.Wearing sunglasses that limit ultraviolet light penetration. 2.Wearing sunscreen with a high number limiting ultraviolet light penetration. 3.Wearing eye protection during activities that put the client at risk for eye injury. 4.Avoiding activities such as reading in dimly lit environments. 5.Eating foods high in vitamin C. 6.Limiting saturated fat intake in the diet.

766. A nurse is discharging a client who underwent outpatient cataract surgery to home. Which interven tion should be included in the discharge instructions to the client and family member? SELECT ALL THAT APPLY. 1.Observe the eye for increased redness,swelling, pain,and decrease in vision,and contact the surgeon if these problems develop. 2.Wear the eye shield at night. 3.Administer eye drops as directed. 4.Cough and deep breathe every 2 hours while awake. 5.Rest in bed with the head of the bed elevated at least 30 degrees. 6.Avoid getting water in the eye when washing the client’s hair.

767. A nurse at the family practice clinic routinely asks middle-aged and older clients if they have experi enced any changes in their vision. Which are early symptoms that should alert the nurse to a client’s on set of cataract formation? SELECT ALL THAT APPLY. 1. Blurring of vision. 2. Difficulty seeing in the dark. 3. Pain in the eye. 4. Increased frequency of headaches. 5. Floating dark spots in the vision field of the affected eye.

768. Which symptoms should a nurse identify when a client asks about symptoms associated with retinal detachment? SELECT ALL THAT APPLY. 1. Redness in an eye. 2. Seeing bright flashes of light. 3. Eye pain. 4. Severe headache. 5. Diminished vision. 6. Seeing floating dark spots in the vision field.

769. A nurse working in a long-term care facility suspects a client is experiencing detachment of the retina. A nurse should: 1. flush the eye thoroughly with saline solution and apply a pressure bandage. 2. apply an eye shield to the affected eye and administer the prescribed oral analgesic medication. 3. notify the primary care provider and have the client transported promptly to a facility for ophthalmologic referral and treatment. 4. patch both eyes and place the client in a prone position.

770.A hospitalized client recently diagnosed with glau coma tells a nurse that he finds it difficult to remem ber to administer the prescribed eye drops. The client states that he does not feel any pain or notice any vi sion changes if he forgets the drops. The best re sponse by the nurse is: 1. “You should be diligent in administering those eye drops or you will need surgery or laser treatments.”. 2. “The medication controls the eye pressure. High pressure in the eye leads to gradual, painless nerve damage affecting sight. Tell me how it’s been for you since your diagnosis of glaucoma.". 3. “Tell me about your usual day so you can fit the eye drops into your schedule.”. 4. “I know this must be hard for you. Not everyone is able to remember everything.”.

771.A client diagnosed with glaucoma is prescribed pi locarpine hydrochloride 1% eye drops to both eyes four times per day. The expected action of this medication is to: 1. increase the outflow of aqueous humor in the eye. 2. improve vision in dimly lit environments. 3. increase production of aqueous humor. 4. increase pupillary dilation.

772.A client is seen in an emergency department and is diagnosed with closed-angle glaucoma. In a review of the client’s medical record, which documented finding should the nurse question?. 1. Eye pain. 2. Sudden onset of symptoms. 3. Normal intraocular pressure. 4. Nausea and vomiting.

773.A nurse, teaching a client with open-angle glaucoma, should instruct the client to: 1. restrict oral intake to lessen the need for glaucoma medications. 2. include foods high in omega 3 fatty acids in the diet. 3. remain under the care of and have regular eye examinations by an eye specialist physician. 4. administer prescribed eye drop medication when feeling pressure within the eyes.

774. A client tells a nurse that he has been diagnosed with macular degeneration, “wet type.” Based on the nurse’s knowledge of this diagnosis, the nurse, exam ining this client’s eyes using an ophthalmoscope, should expect to observe: 1. growth of abnormal blood vessels in the macula. 2. atrophy of structures in the macula. 3. clouding of the lens of the eye. 4. a thin, grayish-white area on the edge of the cornea.

775.A client diagnosed with macular degeneration is told the condition is progressing to an advanced stage. When completing the client’s health assessment, which findings should the nurse expect the client to report? SELECT ALL THAT APPLY. 1. Curtain appearance over part of the visual field. 2. Loss of peripheral vision. 3. Difficulty seeing in dimly lit environments. 4. Visual distortions in the central vision. 5. Clouding of the lens.

776. A client with severely diminished vision has diffi culty with visual discrimination. Which interventions should a nurse recommend to improve the client’s sight in the home environment? SELECT ALL THAT APPLY. 1. Include contrasting colors in the environment but avoid the colors green and blue. 2. Write lists that will be used by the client with a black marker on a white background. 3. Keep light switches the same color as the wall, but place a Velcro® tab at the specific off/on switch. 4. Paint doorknobs on the doors a bright contrasting color. 5. Match the color of dishes with the color of tablecloths or placemats.

777.A client with diminished sight has problems second ary to glare with light. A nurse should advise the client to: 1. install fluorescent lighting throughout the home. 2. wear sunglasses and hats with brims when outdoors. 3. look directly at light sources. 4. utilize direct light from windows during the sunny times of the day.