1. 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.
2. The nurse is providing home care to a client with failing vision due to macular degeneration. The nurse is concerned about the client's safety. Which of the following activities would help to lessen the client's risk of falling?
A.Arranging pieces of furniture close together so the client can use them for guidance and support.
B.Encouraging the client to wear a medical identification bracelet that describes the client's visual deficit.
C.Installing a flashing light to indicate when the phone or doorbell is ringing.
D.Installing handrails in hallways, in bathrooms, and on steps.
A B C D
D
Handrails help to guide the client in his environment as well as provide physical support to enhance stability. Close arrangement of furniture provides dangerous obstacles that could precipitate falls and sharp, hard objects upon which to fall. A medical identification bracelet provides no protection in the event of a fall. Blinking lights that indicate a ringing doorbell or phone are useful for the hearing impaired.
3. Mrs. S with preterm labor will be under Terbutaline (Brethine) therapy. Before beginning the therapy, which of the following assessments would be most important?
A.Estimated fetal size.
B.Maternal heart rate.
C.Contraction intensity.
D.Deep tendon reflexes.
A B C D
B
Terbutaline, a beta-2 selective adrenergic agonist, is used to suppress labor by relaxing the pregnant uterus. In some cases, its beta-2 selectivity is lost, causing cardiac overstimulation. Generally, the drug is contraindicated for a client with a heart rate greater than 130 beats/minute or any cardiac arrhythmias. Therefore, the nurse would need to assess the client's heart rate.
4. Which of the following should be the nurse's initial action immediately following the birth of the neonate?
A.Aspirating mucus from the neonate's nose and mouth.
B.Drying the infant to stabilize the neonate's temperature.
C.Promoting parental bonding.
D.Identifying the neonate.
A B C D
B
The nurse's first action is to dry the neonate and stabilize the neonate's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Promoting parental bonding and identifying the neonate are appropriate after the neonate has been dried.
5. A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost?
A.1 pound.
B.3 pounds.
C.5 pounds.
D.7 pounds.
A B C D
D
1kg=2.2 pounds; therefore, 3.2×2.2=7.04 pounds.
6. Which of the following describes a preterm neonate?
A.A neonate weighing less than 2,500 g (5 lb, 8 oz).
B.A low-birth-weight neonate.
C.A neonate born at less than 37 weeks' gestation regardless of weight.
D.A neonate diagnosed with intrauterine growth retardation.
A B C D
C
A preterm infant is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. Infants weighing less than 2,500 g are described as low-birth-weight neonate. A full-term neonate can be diagnosed with intrauterine growth retardation.
7. The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury?
A.Bend over the object you're lifting.
B.Narrow the stance when lifting.
C.Push or puI1 an object using your arms.
D.Stand close to the object you're lifting.
A B C D
D
Standing close to an object being lifted moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using a larger number of muscle groups distributes the workload.
8. A client asks the nurse what PSA is. The nurse should reply that it stands for
A.prostate-specific antigen, used to screen for prostate cancer.
B.protein serum antigen, used to determine protein levels.
C.pneumococcal strep antigen, a bacteria that causes pneumonia.
D.papanicolaou-specific antigen, used to screen for cervical cancer.
A B C D
A
PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.
9. The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?
A.Poor clotting mechanism.
B.High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood.
C.Persistent fetal circulation.
D.Large, immature liver.
A B C D
D
The primary cause of neonate jaundice is the immaturity of the liver and its inability to break down red cells effectively. Poor clotting mechanisms, elevated Hb, and persistent fetal circulation contribute to the jaundice but aren't causes of it.
10. For a client in addisonian crisis, it would be very risky for a nurse to administer
A.potassium chloride.
B.normal saline solution.
C.hydrocortisone.
D.fludrocortisone.
A B C D
A
Addisonian crisis results in hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.
11. A client with cholecystitis is receiving propantheline bromide. The client is given this medication because it
A.reduces gastric solution production and hypermobility.
B.slows emptying of the stomach and reduces chyme in the duodenum.
C.inhibits contraction of the bile duct and gallbladder.
D.decreases bile secretions.
A B C D
C
Propantheline bromide is classified as a GI anticholinergic; the medication inhibits muscarinic actions of acetylcholine at postganglionic parasympathetic neuroeffector sites. For gallbladder disease, propantheline has an antispasmodic effect on the bile duct and gallbladder. Although the medication reduces production of gastric solutions and also reduces hypermobility, it isn't the main reason for the medication. The drug doesn't slow emptying of the stomach or reduce chyme in the duodenum.
12. In an industrial accident, a client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?
A.A urine output consistently above 100 mL/hr.
B.A weight gain of 4 lb (1.8 kg) in 24 hours.
C.Body temperature readings all within normal limits.
D.An electrocardiogram (ECG) showing no arrhythmias.
A B C D
A
In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 mL/(kg · hr). Thus, the expected urine output of a 155 lb client is 35 mL/hr, and a urine output consistently above 100 mL/hr is more than adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4 lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.
13. A client who has a potassium level of 6 mEq/L should be treated with
A.antacids.
B.IV fluids.
C.fluid restriction.
D.sodium polystyrene sulfonate (Kayexalate).
A B C D
D
Sodium polystyrene sulfonate (Kayexalate) is a resin that pulls potassium into the bowel and is excreted with defecation. Antacids, IV fluids, and restriction of fluids won't reduce the potassium level.
14. A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is LEAST likely to be included in her plan of care?
A.Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes.
B.Allowing the client to ambulate as tolerated.
C.Helping the client use breathing exercises to manage her contractions.
D.Carefully titrating the oxytocin based on her pattern of labor.
A B C D
B
Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.
15. Which of the following is an early sign of laryngeal cancer?
A.Difficulty swallowing.
B.Chronic foul breath.
C.Persistent mild hoarseness.
D.Nagging unproductive cough.
A B C D
C
Hoarseness occurs early in the course of most laryngeal cancers because the tumor prevents accurate approximation of the vocal cords during phonation.
16. The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using
A.antiembolism stockings.
B.oxygen.
C.diuretics.
D.anticoagulants.
A B C D
C
Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess.
17. Which of the following statements about external otitis is true?
A.External otitis is eharaeterized by pain when the pinna of the ear is pulled.
B.External otitis is usually accompanied by a high fever in children.
C.External otitis is usually related to an upper respiratory infection.
D.External otitis can be prevented by using cotton-tipped applicators to clean the ear.
A B C D
A
External otitis is an infection of the external ear. Pain can be elicited when the pinna of the ear is pulled. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external otitis so their use should be avoided.
18. After 5 days of hospitalization, the client who is receiving morphine sulfate for pain control asks for more pain medication with increasing frequency and exhibits increased anxiety and restlessness. His physical condition is stable. What is the probable cause of his behavior?
A.His morphine dosage is too high.
B.His coping mechanisms are exhausted.
C.He is becoming addicted to the narcotic.
D.He has developed tolerance to his narcotic dosage.
A B C D
D
Tolerance to a regular narcotic dose can develop with frequent use. The client experiences increased discomfort, asks for medication more frequently, and exhibits anxious and restless behavior, which are often misinterpreted as indicative of developing dependence or addiction.
19. As part of the annual health screening, the nurse visits the eighth-grade physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing?
A.Slipped epiphysis.
B.Developmental dysplasia of hip.
C.Idiopathic scoliosis.
D.Physical dexterity.
A B C D
C
When bending forward, a person who has idiopathic scoliosis has an obvious rib hump. The two sides of the back at the hips, ribs, or shoulders are not level.
20. Nursing care for a client after electroeonvulsive therapy (ECT) should include which of the following?
A.Nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
B.Bed rest for the first 8 hours after a treatment.
C.Assessment of short-term memory loss.
D.No special care.
A B C D
C
The nurse must assess the level of short-term memory loss. Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. The client might need to be reoriented. The client can get out of bed and eat as soon as he feels comfortable.
21. The nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Which medication would be used to treat his bradycardia?
A.Atropine.
B.Dobutamine (Dobutrex).
C.Bretylium (Bretylol).
D.Lidocaine (Xylocaine).
A B C D
A
IV push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Bretylium is used to treat ventricular fibrillation (VF) and unstable ventricular tachycardia (VT). Lidocaine is used to treat ventricular ectopy, VT, and VF.
22. A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress?
A.Intercostal retractions.
B.Bradycardia.
C.Decreased level of consciousness.
D.Flushed skin.
A B C D
A
Clinical manifestations of respiratory distress include intercostal retractions, tachypnea, tachycardia, restlessness, dyspnea, and cyanosis.
23. Which of the following home regimens should the nurse suggest to relieve itching in children with chicken pox?
A.Generous amounts of fine baby powder.
B.Oatmeal preparation baths.
C.Terrycloth towels moistened with hydrogen peroxide.
D.Cool compresses moistened with a weak salt solution.
A B C D
B
Because of colloidal properties, oatmeal preparation baths often help relieve the itching associated with chicken pox. Calamine lotion can be used also.
24. A 16-year-old student has been admitted to your psychiatric unit after fainting in physical education class. She has a diagnosis of anorexia nervosa, weighs 88 lb (40 kg), and is 5'4" (1.6 m) tall. She has been weighing herself several times per day at home and has lost 30 lb (13.5 kg) in the past 3 months. Which nursing diagnosis would be most appropriate for the client?
A.Disturbed thought processes.
B.Impaired adjustment.
C.Imbalanced nutrition. Less than body requirements.
D.Ineffective sexuality patterns.
A B C D
C
Addressing the client's urgent physical needs is most important. The other diagnoses are possible with anorexia nervosa, but no data in the case study directly support them.
25. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to have which of the following findings?
A.Tension and irritability.
B.Slow pulse.
C.Hypotension.
D.Constipation.
A B C D
A
An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.
26. When completing an assessment of a healthy adolescent client, which of the following would be most appropriate?
A.Obtain a detailed account of the adolescent's prenatal and early developmental history.
B.Discuss sexual preferences and behaviors with the parents present for legal reasons.
C.Discuss the client's smoking with parents present in the room.
D.Assess the adolescent in private; gather additional information from the parents.
A B C D
D
When assessing an adolescent, it is appropriate to first obtain information from the adolescent in private then interview the parents for additional information. Doing so helps to promote independence and responsibility for self-care.
27. When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, the nurse should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate?
A.Neonates. 10.6 to 16.5.
B.3 months. 10.6 to 16.5.
C.3 years. 9.4 to 15.5.
D.10 years. 10.7 to 15.5.
A B C D
A
To sustain them until active erythropoiesis begins, neonates have Hb concentrations higher than those of older children. The normal value of Hb for neonates is 18 to 27g/dL. Disease as well as such nonpathologic conditions as age, sex, altitude, and the degree of fluid retention or dehydration can affect Hb values. The values for a 3-month-old, a 3-year-old, and a 10-year-old are correct as stated above.
28. When assessing a toddler diagnosed with spastic cerebral palsy, which of the following would the nurse expect to find?
A.Toe-walking.
B.Drooling.
C.Facial grimacing.
D.Wide-based gait.
A B C D
A
Spasticity can cause the toddler to stand or walk on his toes due to an upper motor neuron type of muscular weakness resulting in increased muscle tone.
29. Which of the following would be an appropriate expected outcome of nursing care for the client with ulcerative colitis?
A.The client experiences decreased frequency of constipation.
B.The client accepts that an ileostomy will be necessary.
C.The client maintains an ideal body weight.
D.The client verbalizes the importance of restricting fluids.
A B C D
C
An appropriate expected outcome for a client with ulcerative colitis is maintaining an ideal body weight.
30. A female neonate delivered by elective cesarean birth to a 25-year-old mother weighs 3,265g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following?
A.Temperature instability due to type of birth.
B.Respiratory distress due to lack of contractions.
C.Signs of acrocyanosis.
D.Unstable blood sugars.
A B C D
B
The squeezing action of the contractions during labor enhances fetal lung maturity. Neonates who aren't subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding.
Part Two
1. A young adult had a significant reaction to the Mantoux test. What conclusion would the nurse make from the findings?
A.The client has active tuberculosis.
B.The client had active tuberculosis.
C.The client has been exposed to tuberculosis.
D.The client is immunocompromised.
A B C D
C
A reaction to the Mantoux test for tuberculosis means that the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction doesn't mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.
2. A child with type 1 diabetes mellitus develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk for this child?
A.Hypercalcemia.
B.Hyperphosphatemia.
C.Hypokalemia.
D.Hypernatremia.
A B C D
C
Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. Calcium levels aren't directly affected by insulin administration. Hypophosphatemia, not hyperphosphatemia, may occur with insulin administration because phosphorus also enters the cells with insulin and potassium. Sodium levels aren't directly affected by insulin administration.
3. 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.
4. The clinic nurse is instructing a group of parents about emergency treatment for accidental poisoning and injury. Which of the following statements by one of the mothers indicates that she needs further instruction?
A."I should flush my child's eye with room temperature tap water for 15 to 20 minutes if a caustic material gets into it. "
B."I should save the emesis if my child vomits. "
C."I should call the poison control center if there are any symptoms. "
D."I should give 2 to 5 teaspoons of clear fluids after administering ipecac. "
A B C D
C
Many poisons require immediate attention but do not cause immediate symptoms.
5. A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses adequate understanding of nutritional needs during pregnancy?
A."I expect to gain a few pounds each month at first. Then I'll really get big and put on 20 pounds or so. "
B."I guess I will get big and gain 20 to 30 pounds and look pregnant."
C."Because I have to eat for two, I should eat whatever I want whenever I feel hungry. "
D."I will need to eat more so that I will gain about 25 pounds, but I want to make sure I don't fill up with junk food. "
A B C D
D
This statement shows an understanding of nutritional needs during pregnancy. Option A accurately portrays weight gain but doesn't express an understanding of nutritional needs. Option B doesn't show an understanding of either nutritional needs or how and when the weight gain will occur. Option C is a common rationalization that can result in excessive weight gain.
6. The immobile adolescent with a recent fractured femur suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia. Which of the following would the nurse suspect?
A.Atelectasis.
B.Pneumonia.
C.Pulmonary edema.
D.Pulmonary emboli.
A B C D
D
Chest pain and dyspnea in an immobilized adolescent with a large bone fracture suggest a fat embolus. With this condition, fat droplets, rather than a thrombus, are transferred from the marrow into the general blood stream by the venous-arterial route, possibly reaching the lung or brain.
7. A 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprung's disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention takes priority?
A.Changing the surgical dressing.
B.Suctioning the nasopharynx frequently to remove secretions.
C.Irrigating the colostomy with 100 ml of normal saline solution.
D.Auscultating lung sounds.
A B C D
D
Immediately after surgery, the priority nursing intervention is assessing pulmonary function. The surgical dressing shouldn't require changing right away. Suctioning should be performed only if the client can't maintain a patent airway. Colostomy irrigation isn't warranted.
8. Which of the following functions would the nurse expect to be unrelated to the placenta?
A.Production of estrogen and progesterone.
B.Detoxification of some drugs and chemicals.
C.Exchange site for food, gases, and waste.
D.Production of maternal antibodies.
A B C D
D
Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.
9. The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?
A."The cast will be removed in 6 weeks. "
B."A new cast is needed every 1 to 2 weeks. "
C."A short leg cast is applied when the baby is ready to walk. "
D."The cast will be removed when the baby begins to crawl. "
A B C D
B
Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isn't left on for 6 weeks because of the rapid rate of the infant's growth. By the time a baby is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until he is 1 year old.
10. The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP) ?
A.Suction the airway every hour and as needed.
B.Elevate the head of the bed 15 to 30 degrees.
C.Turn the client and change his position every 2 hours.
D.Maintain a well-lit room.
A B C D
B
To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.
11. The nurse is making a plan of care for the child with juvenile rheumatoid arthritis to reduce joint pain in the morning just after arising. Which of the following interventions would be included in the plan?
A.Awakening the child once nightly to exercise the joints.
B.Having the child sleep in a sleeping bag.
C.Having the child sleep with the joints flexed.
D.Increasing pain medication at bedtime.
A B C D
B
Sleeping in a sleeping bag keeps the joints warm, therefore more flexible. Thus, joint pain in the morning would be lessened.
12. Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions?
A.Hyperpyrexia, slow pulse, and weight gain.
B.Tachycardia, weight loss, and mood swings.
C.Hypotension, weight gain, and listlessness.
D.Increased appetite, slowing of sensorium, and arrhythmias.
A B C D
B
Stimulants produce mood swings, weight loss, and tachyeardia. The other symptoms indicate CNS depression.
13. An elderly client's lithium level is 1.4 mEq/L. She complains of diarrhea, tremors, and nausea. The nurse's first action is to
A.hold the lithium (Lithobid) and notify the physician.
B.reassure the client that these are normal adverse effects.
C.administer another lithium dose.
D.discontinue the lithium.
A B C D
A
The client has symptoms of lithium toxicity. Therefore, her lithium should be held and the physician notified immediately. These aren't normal adverse effects, and administering another dose would increase the toxic effects. A nurse can't discontinue a medication without a physician's order.
14. Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience
A.heat intolerance and systolic hypertension.
B.weight gain and heat intolerance.
C.diastolic hypertension and widened pulse pressure.
D.anorexia and hyperexcitability.
A B C D
A
An increased metabolic rate in hyperthyroidism because of excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss--not gain occurs due to the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Heat intolerance and widened pulse pressure do occur, but the other answers are incorrect. Clients with hyperthyroidism experience an increase in appetite--not anorexia.
15. When developing a plan of home care for the client with multiple sclerosis, the nurse should teach the client about which of the following complications most likely to occur?
A.Ascites.
B.Contractures.
C.Fluid volume overload.
D.Myocardial infarction.
A B C D
B
Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications.
16. A registered nurse who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short staffed and needs additional help to care for the clients. The nurse has never worked in the CCU. Which of the following responses is the most appropriate nursing action?
A.Call the hospital lawyer.
B.Report to the CCU and identify tasks that she feels she can safely perform.
C.Speak to the nursing supervisor.
D.Refuse to go to the CCU.
A B C D
B
When the nurse is placed in this situation, the most appropriate action is to set priorities and identify potential areas of harm to the client. Reassignment to another nursing area is an acceptable legal practice used by hospitals to meet their staffing needs. A nurse can't legally refuse to be reassigned unless there's a specific clause in her union contract.
17. After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs'test. What's the purpose of performing this test on a pregnant client?
A.To determine the fetal blood Rh factor.
B.To determine the maternal blood Rh factor.
C.To detect maternal antibodies against fetal Rh-positive factor.
D.To detect maternal antibodies against fetal Rh-negative factor.
A B C D
C
The indirect Coombs'test measures the level of antibodies against fetal Rh- positive factor in maternal blood. Although this test may determine the fetal blood Rh factor, the physician doesn't order it primarily for this purpose. The maternal blood Rh factor is determined be{ore the indirect Coombs'test is done. No maternal antibodies against fetal Rh-negative factor exist.
18. Which pregnancy-related physiologic change would place the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems?
A.Decreased heart rate.
B.Decreased cardiac output.
C.Increased plasma volume.
D.Increased blood pressure.
A B C D
C
Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels.
19. While assessing a client who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects
A.a urinary tract infection.
B.renal calculi.
C.an enlarged kidney.
D.a distended bladder.
A B C D
D
The bladder isn't usually palpable unless it's distended. The feeling of pressure is usually relieved with urination. Reduced bladder tone due to general anesthesia is a common postoperative complication that causes difficulty in voiding. A urinary tract infection and renal calculi aren't palpable. The kidneys aren't palpable above the symphysis pubis.
20. A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that
A.these students are too young to screen; instead, older students should be screened.
B.these students are too old to screen and will no longer benefit from screening for scoliosis.
C.scoliosis screening requires sophisticated equipment and can't be done in school.
D.this is an appropriate request and arrangements will be made as soon as possible.
A B C D
D
Screening for scoliosis should begin at age 10 and be performed yearly until at least age 16. Screening for scoliosis involves inspection of the spine and use of a scoliometer, both of which can be done in a school setting.
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