Comprehensive Test #3

Question 1

A client asks why she feels so much variability in fetal activity each day. The nurse explains that fetal movement is affected by which factors? SATA

1. fetal sleep
2. barometric pressure
3. blood glucose
4. time of day
5. cigarette smoking

Answer 1

1. fetal sleep
2. blood glucose
3. time of day
4. cigarette smoking

Question 2

The parent of a 2 week old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby’s breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor?

1. a normal pattern in infants of this age
2. the need for an apnea monitor
3. a need for close monitoring for the parent
4. the need for a chest radiograph

Answer 2

1. a normal pattern in infants of this age

Question 3

The nurse is discharging a client who has been hospitalized for preterm labor. Which client statement indicates the need for further instruction?

1. “If I think I have a bladder infection, I need to see my obstetrician.”
2. “If I have contractions, I should contact my HCP.”
3. “Drinking water may help prevent early labor for me.”
4. “If I travel on long trips, I need to get out of the car every 4 hours.”

Answer 3

4. “If I travel on long trips, I need to get out of the car every 4 hours.”

Traveling is discouraged if preterm labor has been a problem since it restricts normal movement.

Question 4

A client who has glaucoma has been prescribed timolol eye drops. The nurse should give which instructions about the administration of the eye drops?

1. Instill the eye drops whenever the eyes feel irritated
2. The medication may cause some transient eye discomfort
3. Keep the medication refrigerated between doses
4. The need to use the eye drops will be reevaluated after 1 month

Answer 4

2. The medication may cause some transient eye discomfort

Question 5

A client with severe depression states, “My heart has stopped, and my blood is black ash.” The nurse interprets this statement to be evidence of which problem?

1. hallucination
2. illusion
3. delusion
4. paranoia

Answer 5

3. delusion

Question 6

Which interventions should the nurse use to assist the client with grandiose delusions? SATA

1. Accept the client while not arguing with the delusion
2. Focus on the feelings or meaning of the delusion
3. Focus on events and topics based in reality
4. Confront the client’s beliefs
5. Interact with the client only when the client is based in reality

Answer 6

1. Accept the client while not arguing with the delusion
2. Focus on the feelings or meaning of the delusion
3. Focus on events and topics based in reality

Question 7

A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the HCP for her toddler’s otitis media. What is the nurse’s best response?

1. Instruct the mother on the importance of the medication
2. Ask the mother if she has considered using any medical assistance programs in her community
3. Confer with the HCP about whether a less expensive drug could be prescribed
4. Consult with the social worker

Answer 7

3. Confer with the HCP about whether a less expensive drug could be prescribed

Question 8

Which response is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away?

1. “When you interrupt others, they leave the area”
2. “You’re being rude and uncaring”
3. “You should remember to use your manners”
4. “You know better than to interrupt someone”

Answer 8

1. “When you interrupt others, they leave the area”

This is most helpful because it serves to increase the client’s awareness of others’ perceptions of the behavior by giving specific feedback about the behavior.

Question 9

The nurse transfers a multigravida client who is at 25 weeks’ gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. What should the nurse include in the transfer report to safely manage his client? SATA

1. record of blood pressure trends
2. record of urine protein
3. edema characteristics
4. client use of dietary sodium
5. fetal position
6. fetal heart rate pattern

Answer 9

1. record of blood pressure trends
2. record of urine protein
3. edema characteristics
4. fetal heart rate pattern

Question 10

A client believes she is experiencing PMS. The nurse should next ask the client about what symptom?

1. menstrual cycle irregularity with increased menstrual flow
2. mood swings immediately after menses
3. tensions and fatigue before menses and through the second day of the menstrual cycle
4. midcycle spotting and abdominal pain at the time of ovulation

Answer 10

3. tensions and fatigue before menses and through the second day of the menstrual cycle

Question 11

A client with delirium becomes very anxious and says, “I can’t stop what’s happening to me. Make it stop, please!” What is the nurse’s most appropriate response?

1. “Take some deep breaths. The most you worry, the worse it will get.”
2. “As soon as we know what’s causing this, we can try to stop it. I’ll get you some medicine to help you relax”
3. “I wish I could do something to make it stop, but unfortunately I can’t”
4. “I’ll sit with you until you calm down a little.”

Answer 11

2. “As soon as we know what’s causing this, we can try to stop it. I’ll get you some medicine to help you relax”

Question 12

A hospitalized adolescent with type 1 dm is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client’s breath. The client uses lispro insulin. The last meal was lunch 2 hrs ago. Place the nurse actions in the order in which the nurse should perform them.

1. Obtain a fingerstick test for BG
2. Start an IV infusion with normal saline solution
3. Administer insulin lispro
4. Notify the HCP

Answer 12

1, 4, 2, 3

Question 13

A client who has been recently diagnosed with AIDS inquires about hospice services. What should the nurse tell the client about these services?

Hospice services are appropriate:
1. for clients with an inevitable death within weeks to months.
2. for all clients with AIDS at any stage.
3. only when the client has written advance directives
4. when the client is ready to discuss the prognosis

Answer 13

1. for clients with an inevitable death within weeks to months.

Question 14

What action is most appropriate when dealing with a client who is expressing anger verbally, is pacing and is irritable?

1. convey empathy and encouraging ventilation
2. use calm, firm directions to get the client to a quiet room
3. put the client in restraints
4. discuss alternative strategies for when the client is angry in the future

Answer 14

1. convey empathy and encouraging ventilation

Question 15

The nurse is planning care for a client with a spinal injury who is to remain on complete bed rest. What should the nurse do to prevent the development of pressure ulcers? SATA

1. Turn the client every 2 hrs
2. Insert an indwelling urinary catheter
3. Monitor the serum albumin
4. Monitor the WBC count
5. Request a prescription for a pressure mattress
6. Inspect the skin for redness

Answer 15

1. Turn the client every 2 hrs
2. Monitor the serum albumin
3. Request a prescription for a pressure mattress
4. Inspect the skin for redness

Question 16

A client hospitalized with HF is receiving digoxin and furosemide IV and now has continuous ringing in the ears. What is the appropriate action for the nurse to take at this time?

1. Obtain a digoxin level to check for toxicity
2. Note the observation in the medical record, and plan to reassess in 2 hours
3. Ask the client about taking aspirin in addition to other medications
4. Discontinue the furosemide, and notify the HCP

Answer 16

4. Discontinue the furosemide, and notify the HCP

Question 17

A woman who speaks Chinese only and is very upset brings her child to the clinic with bleeding from the mouth. Which is the appropriate first action by the nurse who does not speak Chinese?

1. Call for the interpreter
2. Grab the child, and take the child to the treatment room
3. Immediately apply ice to the child’s mouth
4. Give the ice to the mother and demonstrate what to do

Answer 17

4. Give the ice to the mother and demonstrate what to do

Question 18

An older adult has few health problems, performs self-care, plays cards, and talks about “the good old days.” The client wants to make “final” arrangements, such as completing an advance directive and planning and paying for a funeral and burial. What interpretation does the nurse make about the client?

1. The client is depressed and should be watched for further signs of depression
2. The request is age-appropriate and should be honored
3. The client should be placed on suicide precautions and seen by a psychiatrist
4. The request suggests that the client has a premonition about dying soon and needs to talk about it

Answer 18

2. The request is age-appropriate and should be honored

Question 19

A primigravid client visits the clinic for a routine examination at 35 weeks’ gestation. The client’s blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, “What should I take if I get an occasional headache after looking at my computer at work all day?” Which OTC med does the nurse consider to be safest for occasional use by a pregnant client with no known risks?

1. acetaminophen
2. aspirin
3. ibuprofen
4. naproxen

Answer 19

1. acetaminophen

Question 20

The nurse is in the process of assessing a non-English-speaking client, communicating through an interpreter. To facilitate communication, what should the nurse do first?

1. Direct all questions to the interpreter
2. Request all family members leave the room
3. Ask client how the client wishes to be addressed
4. Offer the client a cold drink

Answer 20

3. Ask client how the client wishes to be addressed