Part One You will have two hours and 30 minutes to complete Part One.
1. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550mL. What should the nurse do?
A.Increase the frequency of the catheterizations.
B.Insert an indwelling urinary catheter.
C.Place the client on fluid restrictions.
D.Use a condom catheter instead of an invasive one.
A B C D
A
As a rule of practice, if intermittent catheterization for urine retention typically yields 500mL or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of a client with urine retention.
2. While inspecting the client's chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. The nurse suspects which of the following problem from this assessment?
A.Hemothorax.
B.Flail chest.
C.Pneumothorax.
D.Tension pneumothorax.
A B C D
B
Flail chest occurs when two or more adjacent ribs are fractured at two or more sites, resulting in a free-floating segment. This loss of chest wall stability causes respiratory impairment and notable paradoxical chest wall movement. Hemothorax or pneumothorax both decrease chest wall excursion on the affected side. A tension pneumothorax causes a mediastinal shift and tracheal deviation toward the unaffected side.
3. A neonate receives an Apgar score at 1 and 5 minutes after birth. The 5-minute Apgar score is more predictive for which of the following?
A.Residual neurologic damage.
B.Residual respiratory depression.
C.Congenital heart defects.
D.Gestational age of the neonate.
A B C D
A
Apgar scores at 1 and 5 minutes after delivery estimate the severity of respiratory and neurologic depression. Studies have shown a high correlation between a low 5-minute Apgar score and the incidence of residual neurological damage. Apgar scores aren't used to determine the presence of congenital heart defects or the gestational age of the neonate.
4. The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems?
A.Depression is commonly characterized by pain disorders and somatic complaints.
B.Combining evaluations will save time and allow for quicker delivery of health care.
C.Most insurance plans won't cover evaluation of both as separate entities.
D.The physician doesn't have the training to evaluate for psychosocial considerations.
A B C D
A
Psychosoeial factors should be suspected when pain persists beyond the normal tissue healing time and physical causes have been investigated. The other choices may or may not be correct but certainly aren't credible in all cases.
5. The nurse is caring for a client who exhibits signs of somatization. Which of the following statements is most relevant?
A.Clients with somatization are cognitively impaired.
B.Anxiety rarely coexists with somatization.
C.Somatization exists when medical evidence supports the symptoms.
D.Clients with somatization often have lengthy medical records.
A B C D
D
Clients with somatization are prone to "doctor shop" and have extensive medical records as a result of their multiple procedures and tests. Clients with somatization aren't usually cognitively impaired. These clients have coexisting anxiety and depression and no medical evidence to support a clear-cut diagnosis that is causing their symptoms.
6. The nurse is administering sublingual nitroglycerin (Nitrostat) to the client. Immediately afterward, the client may experience which of the following symptoms?
A.Nervousness or paresthesia.
B.Throbbing headache or dizziness.
C.Drowsiness or blurred vision.
D.Tinnitus or diplopia.
A B C D
B
Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.
7. A client with a history of panic attacks seeks to increase social interaction. Each time the client tries to go to the dayroom, she begins to perspire and becomes short of breath. Which action by the nurse will help ease the client's feelings of panic?
A.Have other clients volunteer to accompany the client.
B.Tell the client she has to overcome her fear.
C.Allow the client to stay in her room.
D.Walk with the client and stay with her while she's in the dayroom.
A B C D
D
The client may find security in the presence of a trusted person. Her fears are very real and she'll need the emotional support of caring professionals to overcome them. Telling the client she has to overcome her fears minimizes her feelings. Allowing the client to stay in her room doesn't help the client overcome her feelings of panic.
8. The client is taking lithium (Lithobid). Which instruct should the nurse give to the client?
A.Drink at least six to eight glasses of water per day and to avoid caffeine.
B.Limit the use of salt in his diet.
C.Discontinue medicine when feeling better.
D.Increase the amount of sodium in his diet.
A B C D
A
Caffeine should be avoided because it increases urine output. Clients need to maintain adequate fluid intake to avoid lithium toxicity. Clients should remain on medication even though they're feeling better. Don't limit or increase salt intake because the kidneys will hold onto lithium or excrete it if salt intake varies.
9. The mother of a 9-month-old asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. Which of the following would the nurse instruct the mother to do?
A.Mix new foods with formula or breast milk.
B.Mix new foods with more familiar foods.
C.Offer new foods one at a time.
D.Offer new foods after giving formula or breast milk.
A B C D
C
Infants should be offered new foods one at a time. This gives the infant the chance to become gradually familiar with a variety of food tastes and textures and also helps identify any allergies or adverse reactions to a specific food.
10. Which of the following drugs may be abused because of tolerance and physiologic dependence?
A.Lithium (Lithobid) and divalproex (Depakote).
B.Verapamil (Calan) and chlorpromazine (Thorazine).
C.Alprazolam (Xanax) and phenobarbital (Luminal).
D.Clozapine (Clozaril) and amitriptyline (Elavil).
A B C D
C
Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances.
11. The client with cirrhosis is put on a sodium-restricted diet and a diuretic. The nurse would expect to administer a potassium-sparing diuretic. Which of the follow is a potassium-sparing diuretic?
A.Furosemide (Lasix).
B.Spironolactone (Aldactone).
C.Hydrochlorothiazide (HydroDIURIL).
D.Ethacrynic acid (Edecrin).
A B C D
B
Hypokalemia is an ongoing problem for a client with cirrhosis. When a diuretic is needed, the ideal choice is a potassium-sparing agent. Spironolactone is the diuretic of choice for clients with cirrhosis because it facilitates sodium excretion while conserving potassium.
12. While caring for a healthy neonate female, the nurse notices red stains on the diaper after the neonate voids. Which of the following should the nurse do?
A.Call the physician to report the problem.
B.Encourage the mother to feed the neonate to decrease dehydration.
C.Check the neonate's urine for hematuria.
D.Do nothing because this is normal.
A B C D
D
Female neonates may have some vaginal bleeding in the 1st or 2nd day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician doesn't need to be called. This bleeding is normal and doesn't indicate dehydration or hematuria.
13. A 16-year-old girl comes to the school nurse complaining of cramps, backache, and nausea with her periods. The nurse most likely would interpret these symptoms as which of the following?
A.Pathologic.
B.Physiologic.
C.Psychogenic.
D.Psychosomatic.
A B C D
B
The basis for these symptoms is most likely physiologic. There are two types of dysmenorrhea, primary and secondary. Primary, the most common type, is believed to be caused by an increased level of prostaglandins producing uterine hyperactivity and contractions.
14. The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next?
A.Assess the infusion system, note the client's condition, and notify the physician.
B.Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.
C.Increase the flow rate to infuse an additional 300 mL over the next hour.
D.Maintain the flow rate at the current rate and document any discrepancy in the chart.
A B C D
A
The nurse's most appropriate action is to assess the infusion system to determine the cause of the inaccurate flow rate and to note the client's response to the decreased infusion, especially signs of hypoglycemia. The physician should be notified of the infusion discrepancy.
15. When caring for a client with ulcerative colitis, the nurse should include which of the following nursing interventions in the plan of care?
A.Encouraging the use of stool softeners.
B.Suggesting sitz baths as needed.
C.Arrange for the client to have a private bathroom.
D.Wearing a gown to provide direct care.
A B C D
B
Anal excoriation is inevitable with profuse diarrhea, and meticulous perianal hygiene is essential. Sitz baths are comforting and cleansing.
16. The nurse discusses discharge plan with the parents of a child following a sickle cell crisis. Which of the following would the nurse emphasize the need to seek prompt health care?
A.Headaches and nausea.
B.Fatigue and lassitude.
C.Skin rash and itching.
D.Sore throat and fever.
A B C D
D
Children with sickle cell disease are prone to develop infections as a result of the necrosis of areas within the body and a generalized less-than-optimal health status. If the child with sickle cell anemia develops signs of infection, such as sore throat and fever, prompt evaluation is necessary because an infection can precipitate a crisis.
17. Which of the following factors would be most important in selecting the needle length to use for a subcutaneous injection of hydromorphone hydrochloride?
A.The diameter of the needle.
B.The amount of adipose tissue at the administration site.
C.The amount of medication to be administered.
D.The viscosity of the solution to be injected.
A B C D
B
Needle length depends on the amount of adipose tissue at the site and the angle at which the injection is given.
18. A woman who is 10 weeks pregnant complains about her fatigue and frequent urination. What would be the nurse's response?
A.Recognize these as normal early pregnancy signs and symptoms.
B.Question her further about these signs and symptoms.
C.Tell the client that she'll need blood work and urinalysis.
D.Tell the client that she may be excessively worried.
A B C D
A
Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic.
19. For which type of schizophrenia should the nurse expect to provide the most physical care?
A.Disorganized type.
B.Catatonic type.
C.Paranoid type.
D.Undifferentiated type.
A B C D
B
In catatonic schizophrenia, the client exhibits little reaction to the environment, although periods of excitement may surface at times. Bizarre postures and the inability to feed, wash, and dress oneself are also evident in the catatonic type. Activities of daily living may be affected in varying degrees with the other types but to a lesser extent.
20. The nurse must assess judgment to determine a client's mental status. Which test best accomplishes this?
A.Interpreting proverbs.
B.Spelling words backward.
C.Counting by serial sevens.
D.Discussing hypothetical ethical situations.
A B C D
D
Hypothetical ethical situations--such as "What would you do if you found a wallet containing credit cards and identification?"--are used to test judgment. Proverb interpretation tests thinking. Spelling words backward and counting by serial sevens test concentration.
21. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. Which of the following is the first step the nurse should take to help the woman stop smoking?
A.Assess the client's readiness to stop.
B.Suggest that the client reduce the daily number of cigarettes smoked by one-half.
C.Provide the client with the telephone number of a formal smoking-cessation program.
D.Help the client develop a plan to stop.
A B C D
A
Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation.
22. After teaching the mother about tests performed to monitor the success of the infant's treatment for congenital hypothyroidism, the nurse would determine that the teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of which of the following?
A.Blood electrolyte levels.
B.Metabolic rate.
C.Muscular coordination.
D.Bone age.
A B C D
D
A child with congenital hypothyroidism who is receiving thyroid replacement therapy should be regularly assessed for blood levels of thyroxine and triiodothyronine and also undergo frequent bone age surveys to ensure optimum growth. Results of bone age surveys would demonstrate growth, indicating that the medication was adequate and effective.
23. A client diagnosed with hyperthyroidism has been started on propylthiouracil (PTU) as drug therapy. The nurse should closely observe the client for which of the following side effects?
A.Unusual bleeding or bruising.
B.Hypertension.
C.Hypokalemia.
D.Peripheral edema.
A B C D
A
When taking propylthiouracil (PTU), the client should report any unusual bleeding or bruising as this drug can cause bone marrow depression. Blood tests should be scheduled regularly to detect any hematological changes early.
24. A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub--a classic sign of acute pericarditis. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position?
A.Semi-Fowler's.
B.Leaning forward while sitting.
C.Supine.
D.Prone.
A B C D
B
When the client leans forward, the heart pulls away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis.
25. An 89-year-old client is suffering from dementia of the Alzheimer's type. Which intervention would be most useful in managing his dementia?
A.Provide a safe environment.
B.Provide a stimulating environment.
C.Avoid the use of touch.
D.Use restraints whenever necessary.
A B C D
A
Providing a safe environment will ensure safety when a client has poor judgment, memory loss, and an unsteady gait. Overactivity and noise can overstimulate a client with dementia of the Alzheimer's type by causing agitation. The use of nonverbal communication techniques, such as touch, convey acceptance to the client and can be comforting. The use of restraints can increase a client's agitation.
26. A client is diagnosed with a herniated lumbar disk at the L-5 interspace. Which of the following symptoms would most likely be the one that first caused the client to seek health care?
A.Loss of voluntary muscle control.
B.Loss of bladder control.
C.Back pain that is relieved with resting.
D.Back pain that radiates to the shoulders.
A B C D
C
A typical symptom of a herniated lumbar disk is low back pain that is usually relieved by rest and aggravated by activity that causes an increase in fluid pressure in the spine, such as sneezing, coughing, lifting, and bending. Muscle weakness and sensory losses may occur, and there is generally a change in tendon reflexes.
27. A client who is a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. The client's cervical examination would reveal which of the following?
A.2 cm dilated; 100% effaced at 0 station.
B.4 to 5 cm dilated; 80% effaced at -1 station.
C.2 cm dilated; 50% effaced at +1 station.
D.3 cm dilated; 50% effaced at 0 station.
A B C D
A
The nurse must distinguish between the primigravida and multigravida cervical dilation to make a plan of care for the laboring client. Primigravidas will efface and then dilate, while multigravidas will efface and dilate at the same time.
28. Which of the following is NOT a contributory factor to thermoregulation in the preterm neonate?
A.Immature central nervous system (CNS).
B.Large skin surface area.
C.Lack of subcutaneous (SC) and brown fat.
D.Tendency toward capillary fragility.
A B C D
D
Tendency toward capillary fragility has nothing to do with thermoregulation. The hypothalamus is the site of temperature regulation. In preterm neonates, the CNS is poorly developed, so these neonates may be more prone to temperature instability. The large skin surface area provides the perfect medium for heat toss through evaporation and convection. Lack of SC and brown fat are also contributors to temperature instability. Without SC fat, there is nothing to insulate the infant from heat loss. Brown fat provides calories that help with heat production.
29. The nurse is caring for a client during the fourth stage of labor. Which of the following nursing interventions would be LEAST appropriate?
A.Catheterization to protect the bladder from trauma.
B.Perineal assessments for swelling and bleeding.
C.Vital signs and fundal checks every 15 minutes.
D.Time with the neonate to initiate breast-feeding.
A B C D
A
Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the plan of care during the fourth stage of labor.
30. Which of the following is normal neonate calorie intake?
A.90 to 100 calories per kilogram.
B.110 to 130 calories per kilogram.
C.30 to 40 calories per lb of body weight.
D.At least 2mL per feeding.
A B C D
B
Calories per kg is the accepted way of determining appropriate nutritional intake for a neonate. The recommended calorie requirement is 110 to 130 calories per kg of neonate body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development.
Part Two You will have one hour and 50 minutes to complete Part Two.
1. An adolescent client immobilized in a spica cast complains of having trouble breathing after meals. Which of the following actions would be best?
A.Encourage the client to drink more between meals.
B.Teach the adolescent purse&lip breathing.
C.Give the client a laxative after meals.
D.Offer the client small feedings several times a day.
A B C D
D
A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm resulting in decreased chest expansion and subsequent possible respiratory distress. Because the client's complaints are associated with meals, offering small frequent meals provides nutritional support while minimizing distention.
2. In performing a routine fundal assessment, the nurse finds a client's fundus to be "boggy. " What action should the nurse take first?
A.Call the physician.
B.Massage the fundus.
C.Assess lochia flow.
D.Start methylergonovine as ordered.
A B C D
B
The nurse should begin to massage the uterus so that the uterus will be stimulated to contract. Lochia flow can be assessed while the uterus is being massaged. The client shouldn't be left while the nurse calls the physician. If the fundus remains boggy and the uterus continues to bleed, the nurse should use the call light to ask another nurse to call the physician. An order for methylergonovine may be obtained at this time if needed, or the nurse may administer methylergonovine as written.
3. The nurse instructs the client with hemorrhoids about how to decrease the discomfort. Which of the following interventions would be most likely recommended by the nurse?
A.Decrease fiber in the diet.
B.Decrease physical activity.
C.Take laxatives to promote bowel movements.
D.Use warm sitz baths.
A B C D
D
Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids.
4. A primigravida at 36 weeks' gestation tells the nurse that she has moderate breast tenderness. The nurse teaches the client with some suggestions for relief measures. Which of the following statements by the client suggests the nurse that the client needs further instructions?
A."I should wear a supportive bra at all times. "
B."I should clean my nipples with soap. "
C."I should change my sleeping positions. "
D."I should clean up the colostrum with water. "
A B C D
B
The client needs further instructions when she says she should clean her nipples with soap. Soap can be extremely irritating to sensitive nipples. The client should wear a supportive bra at all times, change her sleeping position, and clean up the colostrum with water.
5. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates which of the following?
A.Absence of nausea and vomiting.
B.Absence of stomach drainage for 24 hours.
C.Passage of mucus from the rectum.
D.Passage of flatus and feces from the colostomy.
A B C D
D
A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned.
6. A client in labor received an epidural anesthetic when her dilation reached 5 cm. Which of the following nursing diagnoses would have the highest priority for her at this time?
A.Impaired skin integrity related to inability to move lower extremities.
B.Impaired urinary elimination related to the effects of the epidural.
C.Deficient knowledge related to lack of information about regional anesthesia.
D.Risk for injury related to hypotension secondary to vasodilation and pooling in extremities.
A B C D
D
The highest priority of care for the client receiving an epidural anesthetic is monitoring blood pressure and preventing hypotension, which is a frequent complication of regional anesthesia. IV fluids are given before the epidural agent to increase blood volume and cardiac output and to minimize hypotension.
7. Which of the following indications is the primary use for electroconvulsive therapy (ECT) ?
A.Severe agitation.
B.Antisocial behavior.
C.Noncompliance with treatment.
D.Major depression with psychotic features.
A B C D
D
ECT is indicated for depression. ECT isn't indicated for severe agitation, antisocial behavior, or treatment noncompliance.
8. When bandaging the burned client's hand, the nurse should pay more attention about which of the following?
A.The bandage is free of elastic.
B.The bandage material is moistened with sterile normal saline solution.
C.The hand and finger surfaces do not touch.
D.The hand and fingers are not elevated above heart level.
A B C D
C
When bandaging the client's fingers and hands, the nurse must ensure that skin surfaces do not touch. Allowing skin surfaces to touch interferes with normal healing and is likely to be irritating.
9. A client with stress incontinence asks the nurse what kind of diet she should follow at home. Which of the following diet regime would most likely be recommended by the nurse?
A.Avoid alcohol and caffeine.
B.Decrease fluid intake.
C.Increase intake of fruit juice.
D.Avoid milk products.
A B C D
A
Clients with stress incontinence should be encouraged to avoid alcohol and caffeine products because both are bladder stimulants.
10. A client who is planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which of the following would be the nurse's best response?
A."Pregnancy is a human process; you don't have to worry. "
B."You practice good health habits; just follow them and you'll be fine. "
C."There is nothing you can do to have a healthy pregnaney; it's all up to nature. "
D."Folic acid, 400 mcg(1mcg= 10μg), improves pregnancy outcomes by preventing certain complications. "
A B C D
D
When counseling a client who is planning to become pregnant, the nurse should discuss the role of folic acid in preventing neural tube defects. The nurse should provide information but not prescribe the drug. It's the client's responsibility to ask the health care provider about a prescription. Telling the client not to worry ignores the client's needs. Practicing good health habits is important for any person. Telling the client that it's up to nature is inaccurate.
11. The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. The nurse explains to the client that the purpose of the tube feedings is to
A.prevent pain from swallowing.
B.prevent fistula development.
C.ensure adequate intake.
D.allow for adequate suture line healing.
A B C D
D
A nasogastric tube is usually inserted during surgery to instill food and fluids postoperatively. The tube allows the suture line to heal adequately, minimizes contamination of the pharyngeal and esophageal suture lines, and prevents fluid from leaking through the wound into the trachea before healing occurs. Normal oral feedings are resumed as soon as the nasogastric tube is removed, usually within 10 days after surgery.
12. Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?
A.Applying cold to limit edema during the first 12 to 24 hours.
B.Instructing the client on the use of sitz-baths if ordered.
C.Instructing the client about the importance of perineal (Kegel) exercises.
D.Instructing the client to use two or more peripads to cushion the area.
A B C D
D
Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.
13. A client has a total serum cholesterol level of 326 mg/dL. The nurse explains to the client that this level
A.is normal and requires no further treatment.
B.is high and will require dietary modification.
C.is low and requires no further treatment.
D.is borderline normal and may require dietary modification.
A B C D
B
A total serum cholesterol level of 326 mg/dL is high. A client with a cholesterol level of 326 will require dietary modifications and may be placed on lipid-lowering medication.
14. Which of the following should the nurse include in a postoperative teaching plan for a client with a laryngectomy?
A.Telling the client to speak by covering the stoma with a sterile gauze pad.
B.Reassuring the client that normal eating will be possible after healing has occurred.
C.Instructing the client to avoid coughing until the sutures are removed.
D.Instructing the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin.
A B C D
B
Normal eating is possible once the suture line has healed.
15. The nurse is developing a plan of care for a client with iron-deficiency anemia. Which of the following would be an appropriate nursing diagnosis of the client?
A.Excess fluid volume related to anemia.
B.Imbalanced nutrition related to nausea.
C.Activity intolerance related to fatigue.
D.Impaired home maintenance related to neurological impairment.
A B C D
C
Fatigue is commonly experienced by clients with iron-deficiency anemia due to reduced oxygen-carrying capacity from low hemoglobin. The fatigue may lead to the client's inability to participate in activity.
16. When caring for a client during the second stage of labor, which action would be least appropriate?
A.Assisting the client with pushing.
B.Ensuring the client's legs are positioned appropriately.
C.Allowing the client clear liquids.
D.Monitoring the fetal heart rate.
A B C D
C
During this time, the client is usually offered ice chips rather than clear liquids. Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate.
17. A few days after a colectomy, a client suddenly develops chest pain, shortness of breath, and air hunger. The nurse knows she must further assess the client's chest pain to determine its origin. When determining whether the chest pain is cardiac or pleuritic in nature, the nurse knows that pleuritic chest pain typically
A.is described as crushing and substernal.
B.worsens with deep inspiration.
C.is relieved with nitroglycerin.
D.is relieved when the client leans forward.
A B C D
B
Pleuritic chest pain is typically described as intermittent, sharp, and very painful and is aggravated with deep inspiration or movement. Crushing, substernal chest pain that is relieved by nitroglycerin is usually of cardiac origin. Leaning forward typically relieves pain associated with pericarditis.
18. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
A.Has perceptions based on reality.
B.Assumes responsibility for actions.
C.Generates new levels of awareness.
D.Has maximum ability to solve problems and learn new skills.
A B C D
C
Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development--not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
19. The nurse notices muscle twitching in the hands and forearms of the client with pancreatitis. The nurse would report these symptoms immediately because clients with pancreatitis are at serious risk for which of the following problems?
A.Hypermagnesemia.
B.Hyperkalemia.
C.Hypoglycemia.
D.Hypocalcemia.
A B C D
D
Hypocalcemia is a major potential complication of pancreatitis. Muscle twitching and irritability are primary symptoms of hypocaleemia. Calcium replacement must begin as soon as hypocalcemia is validated.
20. A 14-year-old girl with Type 1 diabetes is monitoring her blood glucose level at home. Which of the following actions indicates that she understands appropriate care management strategies for a blood glucose level of 250 mg/dL?
A.She will skip the next dose of insulin and drink fruit juice.
B.She will take insulin and drink water.
C.She will eat a high-carbohydrate meal and exercise.
D.She will inject glucagon and rest.
A B C D
B
A blood glucose level of 250 mg/dL is indicative of diabetic ketoacidosis. The client should take insulin to lower glucose levels, drink water to prevent dehydration, and contact her health care provider.
21. A client with a long history of ulcerative colitis takes sulfasalazine (Azulfidine) to control the condition. The nurse would anticipate the client to have which nutritional deficit that can occur as a result of taking this drug?
A.Colbalamin.
B.Folic acid.
C.Niacin.
D.Iron.
A B C D
B
Clients who take sulfasalazine are susceptible to developing impaired folic acid absorption. Common clinical manifestations of a folic acid deficiency are gastrointestinal disturbances such as anorexia, nausea, vomiting, and a smooth, beefy red tongue. The client should be encouraged to eat food high in folic acid such as green leafy vegetables, meat, fish, legumes, and whole grains.
22. A client has been told to take ibuprofen (Motrin, Advil) to relieve the pain of her rheumatoid arthritis. Which of the following statements indicates the client understands how to take this drug safely and effectively?
A."I should not take aspirin with this drug unless my physician says to. "
B."I should not take this drug with antacids or food products. "
C."I do not need to worry about this medicine irritating my stomach. "
D."I should notice the effects of this medicine within the first few days. "
A B C D
A
Ibuprofen can be irritating to the stomach and should not be taken with other drugs that are known gastric irritants such as aspirin.
23. Which of the following is an early symptom of glaucoma?
A.Hazy vision.
B.Loss of central vision.
C.Blurred or "sooty" vision.
D.Impaired peripheral vision.
A B C D
D
In glaucoma, peripheral vision is impaired long before central vision is impaired.
深色：已答题 浅色：未答题