NCLEX Exam 2 Best Questions with Answers Tested and Verified Solutions 2024 Updates Grad, Exams of Nursing

Download NCLEX Exam 2 Best Questions with Answers Tested and Verified Solutions 2024 Updates Grad and more Exams Nursing in PDF only on Docsity! NCLEX Exam 2 Best Questions with Answers Tested and Verified Solutions 2024 Updates Graded A+ Cardiac A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? Metformin A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? Acute Kidney Injury The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? Continue to monitor A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? Check the client's status and lead placement. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? Status of airway The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? Sinus tachycardia The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? The neurovascular status is normal because of increased blood flow through the leg. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A rise in blood pressure A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? Muffled or distant heart sounds The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." The nurse is providing instructions to a client with a diagnosis of hypertension regarding high- sodium items to be avoided. The nurse instructs the client to avoid consuming which item? Antacids The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? Stop smoking because it causes cutaneous blood vessel spasm The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? Elevate the legs higher than the heart The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? Myocardial infarction The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? Hypotension The nurse is performing an assessment on a client with a diagnosis of left-sided heart client to report which sensation during the procedure? Chest pain A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? Weigh self on a daily basis. A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? "I probably will feel tired after the test from lying on a hard x-ray table for a few hours." A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? Oxygen saturation monitor Ear The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? A red, dull, thick, and immobile tympanic membrane A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? Tinnitus The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? Cranial nerve VII, facial nerve The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? Speak at normal tone and pitch, slowly and clearly. A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? Avoid sudden head movements. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? Speak at a normal volume. Endocrine A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? Intravenous infusion of normal saline An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. Comatose state, Deep, rapid breathing, Elevated blood glucose level The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. Shakiness, Palpitations, Lightheadedness A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? Convey empathy, trust, and respect toward the client. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short- acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? IV fluids containing dextrose The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? Polyuria The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? Inadequate fluid volume The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? "I need to stop my insulin." The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? Test the drainage for glucose. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? Temperature The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. Feeling cold, Loss of body hair, Persistent lethargy, Puffiness of the face A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? Respiratory distress A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. Fever, Nausea, Tremors, Confusion The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Instruct the client about thyroid replacement therapy Encourage the client to consume fluids and high-fiber foods in the diet Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? "Usually these physical changes slowly improve following treatment." The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? To treat hypocalcemic tetany A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? Take a blood glucose test before exercising. The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. A thyroid-releasing inhibitor will be prescribed, Encourage the client to consume a well- balanced diet. A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? The client needs immediate education before discharge A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? "Let me go over the types of insulins with you again." A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? Glucagon A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? Regular insulin via the intravenous (IV) route The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? Positive Trousseau's sign The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication should be included on the list? Increased thirst The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence? Increased production of glucose The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? Severe abdominal pain Eye The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? Eye medications will need to be administered for life. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? A sense of a curtain falling across the field of vision The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? Blurred vision The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. Avoid activities that require bending over, Take acetaminophen for minor eye discomfort, Place an eye shield on the surgical eye at bedtime, contact the surgeon if a decrease in visual acuity occurs Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? Note the time of day the test was done A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? Instruct the client that he or she may need glasses when driving A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? Cardiovascular disease A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? Placing an eye patch over the client's affected eye The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? Client report of tunnel vision The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? "The hearing aid should not be worn if an ear infection is present." The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. Nuts, Liver, Lentils The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? Document the findings. Expected drainage will range from 500 to 1000 mL/day. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A rigid, boardlike abdomen The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? Irrigating the nasogastric tube The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? Limit the fluids taken with meals. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. Maintain NPO (nothing by mouth) status, Encourage coughing and deep breathing., Give hydromorphone intravenously as prescribed for pain. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? "I should increase the fiber in my diet.” The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? Ask the client to extend the arms.-Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? Pasta with sauce The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? Pain relieved by food intake A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? Lying recumbent following meals The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? Purple discoloration of the stoma A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? This is a normal, expected event. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? Fluid and electrolyte imbalance The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? "I need to limit my intake of dietary fiber.” The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? Sweating and pallor A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? Assessment of vital signs The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? Inability to pass flatus The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? Dark red drainage A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? "I can go back to work right away.” -Rest is especially important until laboratory studies show that liver function has returned to normal. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? Leukocytosis with a shift to the left After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? Waves of loud gurgles auscultated in all 4 quadrants -Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? Pernicious anemia A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? "I eat at least 3 large meals each day.” The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? Check the suction device to make sure it is working. The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? Decreased hemoglobin A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? Applesauce and a graham cracker The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. Jaundice, Clay-colored stools, Elevated bilirubin levels, Dark or tea-colored urine The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? "I need to decrease fiber in my diet." Hematological A client enters the hospital emergency department with a nosebleed. On assessment the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action? Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? Red tongue that is smooth and sore -Tell the client to avoid any woody, grassy areas that may contain ticks. -Instruct the client to immediately start to take the antibiotics that are prescribed. -Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 10.The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? Positive punch biopsy of the cutaneous lesions 11. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. -Record site, date, and time of the test. -Give the client a list of potential allergens if identified. 12.The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? Bananas 13.A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? Ensure that the client uses an electric razor for shaving. 14.The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? Fever, hypertension, and graft tenderness 15.A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? Complete blood cell (CBC) count 16.A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? Amylase 17.A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? CD4+ cell count 18.A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? Infection caused by leukopenic effects of the medication 19.A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage? Skin rash 20.Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? Cardiac conduction deficits 21.The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? Complaints of joint pain 22.A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action? Tell the client to return to the clinic in 4 to 6 weeks. 23.A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? A 14 to 21 day course of doxycycline 24.The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? Facial rash 25.A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? A Western blot will be done to confirm these findings. 26. The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? Lesion is highly metastatic Lesion is a nevus that has changes in color. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. A pearly papule with a central crater and a waxy border Location in the bald spot atop The head that is exposed to outdoor sunlight A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A white color to the skin, which is insensitive to touch -Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? Partial-thickness skin loss of the dermis An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 36% The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? Return of distal pulses- The escharotomy releases the tourniquet-like compression around the arm The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? Elevated hematocrit levels- the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? Urine output The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? Immobilization of the affected leg The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun Examine your body monthly for any lesions that may be suspicious. The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Multiple straight or wavy threadlike lines underneath the skin The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? "Apply a warm, damp washcloth if discomfort occurs.” The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. Reposition every 2 hours., Use a bed cradle as indicated. Apply protective pads to heels and elbows Provide perineal care every 8 hours and after incontinence. The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? Gastric lavage The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder? A client who tans in an indoor tanning bed The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client? "The local anesthetic may cause a stinging sensation.” The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? "I will return tomorrow to have the sutures removed.” The nurse prepares to assist the health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care? Tell the client that the procedure is painless. The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client? Keep the test sites dry. The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? Apply emollients to the skin after bathing. The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? It is caused by a tick bite. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? "This skin infection involves the deep dermis and subcutaneous fat.” The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? Applying warm compresses to the affected area The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? Clustered skin vesicles The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statements? Select all that apply. "I need to clean the site as prescribed to prevent infection.” "I need to expect some swelling and tenderness in the affected area.” The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? Apply an emollient lotion to the skin to enhance softening. Musculoskeletal The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? A sedentary 65-year-old woman who smokes cigarettes The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? I need to report a fever or swelling to my health care provider The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? Stay with the victim and encourage him or her to remain still. Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. Rewrap the residual limb with an elastic compression bandage A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? Bending or lifting The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? Temperature of 101.6°F (38.7°C) orally The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? Uric acid level of 9.0 mg/dL (0.54 mmol/L) A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? Check the weights to ensure that they are off of the floor The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? Place a clock and calendar in the client's room The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? Signs of skin breakdown The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? The need for sensory stimulation The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? All caregivers should be told about the metal implant The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? Use a fracture pan for bowel elimination The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? The client's vital signs, muscle strength, and previous activity level The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? Within 20 to 30 minutes of application The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? Call the health care provider The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? Petal the cast edges with appropriate material Neurological 1. The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? Nail bed pressure 2.The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? Exhaling during repositioning 4.A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid separates into concentric rings and tests positive for glucose. 5. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. -Keeping the linens wrinkle-free under the client – Preventing unnecessary pressure on the lower limbs – Turning and repositioning the client at least every 2 hours 6.The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? Flaccid paralysis 7.The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. -Loosening restrictive clothing -Removing the pillow and raising padded side rails - Positioning the client to the side, if possible, with the head flexed forward 8.The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. -The client is aphasic. -The client has weakness on the right side of the body. -The client has weakness on the right side of the face and tongue. 9.The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to remind him to turn his head to scan the lost visual field." 10.The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? Consistently uses adaptive equipment in dressing self 11. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? Taking medications as scheduled 12. The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? "I don't need to use my walker to get to the bathroom." 13.The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? "I'll try to eat my food either very warm or very cold." 14.The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? "I need to be sure to consume foods that are low in sodium." 24. The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? Contact the health care provider (HCP). 25.A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? A hearing aid 26. The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. -Providing sensory cues -Giving simple, clear directions -Providing a stable environment -Keeping family pictures at the bedside 27. The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. -Keep suction equipment at the bedside. -Elevate the head of the bed 30 degrees. - Keep the head and neck in good alignment -Administer prescribed respiratory treatments as needed. 28.The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? Explaining equipment and procedures on an ongoing basis 29.Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? It is possible the client can hear the family. 30.The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? A neuropsychologist 31.The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? Oncology 1. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? Increased calcium level 2. The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? Encouraging fluids 3. client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? Enlarged lymph nodes 4. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? Abdominal distention 5. The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. Facial edema in the morning Serum calcium level of 12 mg/dL (3.0 mmol/L) Numbness and tingling of the lower extremities 6. A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? The development of a vesicovaginal fistula 7. The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply. Pathological fracture Urinalysis positive for nitrites Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) 8. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? Age younger than 50 years 9. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? Change the dressing as prescribed 10. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? Hematuria 11. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? "I empty the urinary collection bag when it is two-thirds full." 12.A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. Radiation Chemothera py Serum sodium level determination Medication that is antagonistic to antidiuretic hormone 13. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? Periorbital edema 14.The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency? Electrocardiographic changes 15. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? "I'm going to take aspirin for my headache as soon as I get home." 16.A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. Peritonitis Hemorrhage Fistula formation Bowel perforation 17. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? Elevating the affected arm on a pillow above heart level 18.The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? Elevated on a pillow 19.The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? "I will limit sun exposure to 1 hour daily." 20. The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. 8. A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? Tender, indurated prostate gland that is warm to the touch 9. The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? Decreased force in the stream of urine 10.The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. Check the level of the drainage bag. Reposition the client to his or her side. Place the client in good body alignment. Check the peritoneal dialysis system for kinks. 11. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? Pallor, diminished pulse, and pain in the left hand 12. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? Elevated creatinine level 13.A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5°C (101.2°F). Which nursing action is most appropriate? Notify the health care provider. 14. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? Notify the health care provider (HCP). 15.A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. Insertion of a nephrostomy tube Placement of a ureteral stent with ureteroscopy 16. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? Hyperglycemia 17. A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? Increased immunosuppression therapy 18. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute 19.The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? Headache, deteriorating level of consciousness, and twitching 20.The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. Nocturia Incontinence Enlarged prostate 21. The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period? Pale pink urine 22. A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further teaching when he states that he will perform which movement as part of these exercises? Bearing down as if having a bowel movement 23.A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client? Hypertension 24. The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process? Presence of family 25. The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? Red blood cell (RBC) count 26.A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. "The uterus is composed of 3 layers: endometrium, myometrium, and perimetrium." 5. A preadolescent client asks the nurse about the onset of puberty. The nurse describes which changes as indicating puberty? Select all that apply. Mood swings occur Pubic hair will develop. Breast development begins. Height will increase due to a growth spurt. 6. The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply. A blood test will confirm the diagnosis Syphilis signs and symptoms are divided into stages. Syphilis can be spread through vaginal, anal, or oral sex. 7. The nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which assessment question would assist in eliciting the most specific data regarding the cause of this syndrome? "Do you use tampons during your menstrual period?" 8. The clinic nurse has provided instructions regarding home care measures to a female client diagnosed with pelvic inflammatory disease (PID). Which statement, if made by the client, indicates an understanding of these measures? "I need to avoid tight-fitting clothing." 9. A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? "Have you had any vaginal discharge?" 10.The nurse employed in a fertility clinic is providing information to a couple considering in vitro fertilization. The nurse's explanation should most appropriately include which information? Select all that apply. A fertilized ovum is transferred into the woman's uterus. Mild spotting or cramping may occur following egg removal. A medication protocol for follicle development will be prescribed. 11. The nurse is performing an assessment on a client who asks how she might recognize when she is ovulating. The nurse should explain that which occurs at ovulation? Select all that apply. Breast tenderness Small amount of vaginal spotting Lower abdominal pain known as Mittelschmerz Presence of spinnbarkeit–thin and clear mucous discharge 12. An adolescent seen in the health care clinic has been diagnosed with endometriosis. The client asks the clinic nurse to describe this condition. Which response should the nurse provide? "It is the presence of tissue outside the uterus." 13.The nurse is providing teaching to a transgender female to male client who will be started on testosterone therapy. Which information should the nurse include in the teaching session? Select all that apply. Expect the clitoris to enlarge. Liver enzymes and cholesterol levels will need to be monitored. 14.The instructor asks a nursing student to identify the phases of the ovarian cycle. Which phases identified by the nursing student indicate an understanding of the ovarian cycle? Select all that apply. Luteal phase Follicular phase Ovulatory phase 15. A client with a history of ovarian cysts is seen by the health care provider (HCP). The client has had 2 previous surgeries related to this condition. Her HCP recommends an exploratory laparoscopic procedure for the current ovarian cyst, which has persisted for several months. The client states that the prior ovarian cysts were benign and questions the need for this procedure. Which response is best for the nurse to provide? "A prolonged ovarian abnormality should be evaluated thoroughly." 16.The client has a regular 32-day cycle. She asks on which day she most likely ovulates. How should the nurse reply? Day 18 17.A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply. "Some forms of HPV can lead to cervical cancer." "HPV is most commonly spread during vaginal or anal sexual contact." "In some types, HPV will go away on its own and does not cause health issues." 18.The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. How should the nurse respond? Select all that apply. "It is the presence of tissue outside the uterus that resembles the endometrium." Major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia." Respiratory 1. The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 21. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? Venturi mask 22. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? Sitting up and leaning on an overbed table 23. The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum 24. he nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? Sputum culture 25.The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. Sitting up and leaning on a table Standing and leaning against a wall Sitting up with the elbows resting on knees 26. A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? Bloody 27. The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? Deflate the cuff on the tube. 28.The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing Encouraging active range-of-motion exercises 29. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? Document the findings 30. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initialnursing action? Perform a focused respiratory assessment. 31.The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 32.The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate? Continue to monitor the client. 33. The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 34.The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? Hyperoxygenate the client. 35.The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? Suctioning the client every hour 36. The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed? The nurse places 1 finger loosely between the tie and the neck. 37. The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action? Suction the ET tube. 38.The nurse is caring for a client who is mechanically ventilated, and the high- pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. Water or a kink in the tubing Biting on the endotracheal tube Increased secretions in the airway 39. The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made? Coughing occurs with suctioning. 40. A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? Respiratory rate of 16 breaths/minute Antepartum The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. -The ductus arteriosus allows blood to bypass the fetal lungs -One vein carries oxygenated blood from the placenta to the fetus -Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? It connects the umbilical vein to the inferior vena cava A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? The appearance of the fetal external genitalia The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? Notify the health care provider (HCP) The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? It promotes the fertilized ovum's normal implantation in the top portion of the uterus The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. Allows for fetal movement Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus Can be used to measure fetal kidney function A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? Do you plan to have any other children? The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? I will maintain strict bed rest throughout the remainder of the pregnancy The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. Routine administration of subcutaneous heparin may be prescribed An overbed lift may be necessary if the client requires a cesarean section Thromboembolism stockings or sequential compression devices may be prescribed The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? The client has a history of cardiac disease The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? The iron is best absorbed if taken on an empty stomach A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to the chart below. History and Physical Laboratory and Diagnostic Results Medications Gravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0 Venereal Disease Research Laboratory (VDRL) nonreactive Prenat al vitamin s Weight 135 lb (61 kg) Rubella immune Positive Goodell and Chadwick Rh positive, Type O You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? I will eat fresh fruits and vegetables for snacks and for dessert each day The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? Refer to Figure. Normal The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply. -Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high -The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client? This is necessary to assist in identifying potential infections that may need to be treated A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client? The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding? Fundus is at the appropriate level The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? The client has a history of hypertension During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? Diet and insulin needs change during pregnancy The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction? During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason? Reduce excessive maternal stress and fatigue The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? Whole-grain cereal The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? Leafy green vegetables A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply. The client is wearing knee-high nylon stockings The client is wearing sweatpants with snug elastic ankle bands A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction? I should do more exercises to strengthen my back muscles A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? Drink 8 glasses of water per day A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response? This test measures amniotic fluid volume and fetal activity The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem? I want to gain only 10 pounds because I want to have a small, petite baby A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? Monitor for fetal movement A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? Reduce external stimuli A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? A private room 2 doors away from the nurses' station A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure? The procedure is performed using artificial insemination of sperm instilled through the vagina The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes? Select all that apply. Places the client at risk for dystocia Has an increased probability of cesarean section Has a flat shape that may impede fetal descent The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. Plan for weekly nonstress tests at 32 weeks Obtain nutritional counseling with a dietitian The nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid? Spinach The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? Calcium gluconate injection A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client? Pain, itching, and vaginal discharge The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd). 1116 The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness? Compression of the vena cava A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? I should wear underwear with a cotton panel liner The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and should tell the client that which change may persist after she gives birth? Striae gravidarum Intrapartum The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. - A gravida II who has just been diagnosed with dead fetus syndrome - A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The cervix is dilated completely The spontaneous urge to push is initiated from perineal pressure The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? Administer oxygen via face mask The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? Fetal heart rate of 180 beats/minute The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the –1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer. The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? Provide pain relief measures The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? Perform a vaginal examination every shift The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? Monitoring the fetal heart rate The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? The client's fear The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. Petechiae Hematuria Prolonged clotting times Oozing from injection sites The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? Forceps delivery The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? Breathe rapidly The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? Every 15 minutes The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? Palpating the maternal radial pulse while listening to the FHR The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? A fetal heart rate of 90 beats/minute The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? Continuous electronic fetal monitoring The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? Placental separation During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? Prevent dehydration and hypoxemia A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? Measure fundal height The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? Clear and maintain an open airway A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? Painless vaginal bleeding A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. Increase in fundal height Hard, boardlike abdomen Persistent abdominal pain The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? Pale straw in color, with flecks of vernix A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? Continue to monitor the client The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. Keep the room semi-dark Initiate seizure precautions Pad the side rails of the bed Avoid environmental stimulation The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? Monitoring the mother's blood pressure The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? Assess the fetal heart rate The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? Moderate variability present The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? Click on the image to indicate your answer. Image #1 is the correct answer (To assess the brachioradialis reflex, the client's thumb is held to suspend the forearm in relaxation. The nurse then strikes the forearm directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and supination of the forearm) The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? Encourage an upright or side-lying maternal position The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? Assess for signs and symptoms of labor The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? Butorphanol tartrate -Irritability, -Poor feeding The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? The mother bathes the newborn infant after a feeding.-It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation. A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? Indicates the presence of maternal infection The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? A bottle of sterile normal saline The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions.” The nurse is preparing to instruct a client on how to bathe a newborn. Which statement should the nurse include in the instruction? "Begin with the eyes and face.” The nurse is preparing to administer an injection of vitamin K to a newborn and provides the mother with information about the injection. Which information should the nurse provide? "The injection is extremely important to prevent bleeding in your baby.” The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? Make a loud, abrupt noise to startle the newborn. A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL (238 mcmol/L). The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? Assessing skin integrity and fluid status of the newborn The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100 beats per minute, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. What should be the immediate nursing intervention for this newborn? Oxygen supplementation and suctioning The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? Document the findings. The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? Administer oxygen via resuscitation bag to the newborn infant. The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only 2 vessels. How should the nurse interpret this finding? Finding 2 vessels may indicate an increased risk for other congenital anomalies. The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which findings? Select all that apply. -A copper-colored skin rash, -Mucopurulent nasal drainage (snuffles) To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement? Place a warm blanket on the examining table before placing the newborn on the table. The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine? The newborn requires some resuscitative interventions. The nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? Periodic well-baby examinations The nurse is preparing to teach a new mother how to sponge bathe a 1- day-old newborn. Which actions should the nurse take? Select all that apply. -Pat the baby dry gently., -Support the newborn's body during the bath., -Make sure that the room temperature is 75°F (23.9°C)., -Cleanse one body area at a time keeping other body areas covered. On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? At 1 minute after birth and 5 minutes after birth The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? 10 The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the vital signs are within normal range if which set of vital signs is noted on assessment? Heart rate 130 beats/minute, respirations 46 breaths/minute-12 0 to 16 0 b e a t s / m in , 3 0 to 6 0 breaths/minute. The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply. -A soft and flat anterior fontanel, -A triangular-shaped posterior fontanel The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider (HCP) has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? Edema resulting from bleeding below the periosteum of the cranium The nurse is admitting a newborn infant to the nursery and notes that the health care provider (HCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? Select all that apply. -Protect defect from trauma., -Maintain a thermoneutral environment., -Assess for associated birth defects such as cleft palate. Which statement, if made by the mother of a 1-day-old newborn, indicates the understanding of gastrointestinal system functioning in the infant? Select all that apply. -10 to 20 mL is the stomach capacity of a 1-day-old newborn, -90 to 150 mL is the stomach capacity of a 1-month-old infant A new mother reports that her niece was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's mother asks the nurse if her newborn also has this diagnosis. Which findings should the nurse identify as potential indicators of GER? Select all that apply. -Irritability, -Failure to thrive, -Choking with feeding, -Spitting up and regurgitation The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings should the nurse most specifically expect to note in the infant? Select all that apply. -Failure to thrive -Coughing, wheezing, and short periods of apnea An infant is born to a mother with hepatitis B. Which prophylactic measure is indicated for the infant? instruction should the nurse include? The diet should include additional fluids. 13.The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? Massage the fundus until it is firm. 14.The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? The client with lochia that is red and has a foul-smelling odor 15. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? Notify the health care provider (HCP). 16. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? "I will begin abdominal exercises immediately." 17.After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? Support the mother in her reaction to the newborn infant. 18.The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? An increase in the pulse rate from 88 to 102 beats/minute 19. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. -Wear a supportive bra. -Rest during the acute phase. -Maintain a fluid intake of at least 3000 mL/day. -Continue to breast-feed if the breasts are not too sore. 20. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? "I should wash my nipples daily with soap and water." 21.The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? Enlarged, hardened veins 22.The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A multiparous client who delivered a large baby after oxytocin induction 23. A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? Encouraging fluid intake 24.The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? Changes in vital signs 25.The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? Prepare an ice pack for application to the area. 26.On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? Massage the fundus until it is firm. 27. On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? "Foods and fluids that will increase urine alkalinity should be consumed." 28.A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? Postpartum infection 29.Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? Blood pressure cuff 30.The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider (HCP), what is the nurse's next action? Prepare the client for surgery. 40. The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction? "I need to isolate the infant for 48 hours after beginning the antibiotics." 41.A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? Concern about the loss of the baby and personal health 42.The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? "You should not become pregnant for 2 to 3 months after administration of the vaccine." 43.The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 44.The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? The mother requests that the nurse feed the newborn because she is feeling fatigued. 45.The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs? Retained placental fragments from delivery 46.The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis? Abdominal tenderness and chills 47.Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? Encourage the client to take pain medication as prescribed.