upto 220 Flashcards
A female baby was born with talipes equinovarus. Her mother has requested that the nurse
assigned to the baby come to her room to discuss the baby’s condition. The nurse knows that the
pediatrician has discussed the baby’s condition with her mother and that an orthopedist has been
consulted but has not yet seen the baby. What should the nurse do first?
Question the mother and find out what the pediatrician has told her about the baby’s condition.
What specific hormone must be present in serum or urine laboratory tests used to diagnose
pregnancy?
Human chorionic gonadotropin
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes
progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?
Secretory phase
The nurse is caring for a client with pancreatitis. Which of the following IV medications would
the nurse expect the physician to prescribe for control of pain in this client?
Meperidine (Demerol)
The nurse begins morning assessment on a male client and notices that she is unable to
palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing
this finding?
Use a Doppler to determine presence and strength of these pulses.
A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first
psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the
following diagnostic tests are essential prior to the initiation of lithium therapy with this client?
Blood urea nitrogen, electrolytes, and creatinine
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a
thorough medical evaluation, a diagnosis of Alzheimer’s disease was made. An appropriate nursing
intervention to decrease the anxiety of this client would include:
Allowing the client to perform activities of daily living as much as possible unassisted
On the third postpartum day, a client complains of extremely tender breasts. On palpation,
the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle
feeding. The nurse should initially recommend to her to:
Apply ice packs to the breasts and wear a supportive, well-fitting bra
While changing the dressing on a client’s central line, the nurse notices redness and warmth
at the needle insertion site. Which of the following actions would be appropriate to implement based
on this finding?
Document in the nurse’s notes and notify the physician after redressing the site.
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has
been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago;
the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living
and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
3-1-1-0-2
A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior
wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of
breath. Crackles in both lung bases are audible on auscultation. He is developing:
Pulmonary edema
After a liver biopsy, the best position for the client is:
Right lateral
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should
call the physician to report:
Temperature rise to 102_F rectally
A 67-year-old man had a physical examination prior to beginning volunteer work at the
hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was
180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of
hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an
exercise regimen. On his next visit, compliance would best
be determined by:
A blood pressure reading of 130/70 with a 5-lb weight loss
The physician has ordered that a daily exercise program be instituted by a client with type I
diabetes following his discharge from the hospital. Discharge instructions about exercise should
include which of the following?
A snack may be needed before and/or during exercise.
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium
level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular
insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:
Drive potassium from the serum back into the cells
A 26-year-old female client presents at 10 weeks’ gestation. She currently is a G3 1-0-1-1. Her
mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes.
The client’s previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches
tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in
pregnancy. Which of the following factors places her at risk for gestational diabetes?
Previous birth of an infant weighing>9 lb
When assessing residual volume in tube feeding, the feeding should be delayed if the amount
of gastric contents (residual) exceeds:
50 mL
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is
hospitalized for additional tests and to begin a course of chemotherapy designed to induce a
remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow
test previously and is apprehensive about having another. Which of the following interventions will
be most effective in relieving her anxiety?
Explain what will take place and what she will see, feel, and hear.
A female client was employed as a client care technician in a hemodialysis unit. She recently
began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted
that her urine was tea colored, which she rationalized was a result of the vitamins she began taking
to alleviate fatigue. She was diagnosed with hepatitis B.
After a brief hospital stay, she is discharged to her parent’s home. Her mother asks the nurse if any
precautions are necessary to prevent transmission to the client’s family. The nurse explains necessary
precautions, which include:
Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride
solution
A 29-year-old client delivered her fifth child by the Lamaze method and developed a
postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may
experience?
Rapid pulse; narrowed pulse pressure; cool, moist skin
A successful executive left her job and became a housewife after her marriage to a plastic
surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The
client’s behavior can be described as:
Conversion reaction
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is
to:
Auscultate fetal heart rate
A client’s wife is concerned over his behavior in recent months. He has been diagnosed with
Parkinson’s disease, and she is telling his nurse that he has been doing “strange things.” The nurse
reassures the wife that the following behavior is normal with Parkinson’s disease:
“Your husband may move his hands in motions that look like he is rolling a pill between his
fingers.”
A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who
reported bizarre behavior. Except for going to work, she spends all her time in her room and
expresses concern over neighbors spying on her. She has fears of the telephone being “bugged.” Her
diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason
for this plan would be to:
Enable her to develop trust
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm.
Which of the following statements will be reflected in the client’s chief complaint?
“I don’t remember anything in particular, I just haven’t felt well.”
A 26-year-old male client is brought by his wife to the emergency department (ED)
unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes.
An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent
diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar
level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?
Regular insulin by IV infusion
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular
disorder. She arrives in her
room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is
cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine
if these muscle spasms are indicative of intermittent claudication, the nurse would begin her
assessment with the following question:
“Do your muscle spasms occur following rest, walking, or exercising?”
A client’s behavior is annoying other clients on the unit. He is meddling with their belongings
and dominating the group. The best approach by the nurse is to:
Set limits on his behavior.
A behavioral modification program is recommended by the multidisciplinary team working
with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would
include:
Restriction to the unit until she has gained 2 lb
An alcoholic client who is completing the inpatient segment of a substance abuse program
was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge
instructions?
The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is
discontinued.
The postpartum nurse should include which of the following instructions to breast-feeding
mothers?
Daily caloric intake should be increased by 500 cal.
At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing
measure should be included in her plan of care to help alleviate it?
Eat small, frequent bland meals.
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse
would expect which of the following to be present in relation to his blood sugar level?
An increased blood sugar level
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic
blood studies is characteristically abnormal in this disorder?
Partial thromboplastin time
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this
may be a reaction to which of the following medications if applied in large amounts?
Mafenide acetate
