Results
#1. A 38-year-old client, who is gravida 4, para 2 with gestational diabetes, is scheduled for an amniocentesis at 33 weeks’ gestation because of unstable blood sugar. The results of the amniocentesis reveal the lecithin/ sphingomyelin ratio (L/S) is 1:1, and the phosphatidylglycerol (PG) is negative. How should a nurse best interpret this data?
#2. A client, who is overweight and has diabetes, has a blood pressure of 148/92 mm Hg. The client’s urinalysis reveals microalbuminuria. The client does not want to take drugs despite a family history of brain attack (cerebrovascular accident [CVA]). The correct response by a nurse is ?
#3. Which clinical feature found on assessment should indicate to a nurse that a client has congestive heart failure? ?
Reduce cardiac output and circulating o2 producing fatigue and SOB.
#4. A 4-year-old is hospitalized with acute glomerulonephritis. A nurse should feel most confident that the client teaching has been effective and the child has a basic understanding of this condition if the child states ?
#5. The nurse is conducting a seminar on sudden infant death syndrome (SIDS) with a group of first-time parents of new-borns. The nurse’s teaching should emphasize ?
#6. The laboratory values for an adult client who is NPO are: Na+ 128, K+ 3.5, and glucose 130. Which IV solution should a nurse expect will be ordered?
#7. A client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion has a Na+ of 128 mEq/L and is confused. A nurse’s primary goal should be to: ?
Because SIADH causes water retention and dilutional hyponatremia .
#8. A group of clients who are pregnant are attending a childbirth preparation class. A nurse is discussing the effects of cigarette smoke on fetal development. Which characteristic should the nurse describe as being associated with babies born to mothers who smoked during pregnancy?
#9. The school nurse inspects the toddlers attending the school’s day-care center. Which observation by the nurse is cause for follow-up for pinworms?
#10. A client, who is gravida 4, para 2, is admitted to a labor and delivery unit. A nurse performs a vaginal examination and determines that the client’s cervix is 6 cm dilated, 75% effaced, and a +1 station. Based on the nurse’s assessment, in which stage of labor is this client ?
#11. A client is admitted with a history of an abdominal aortic aneurysm. A nurse should know that the client has an impending rupture of the aneurysm if the client reports: ?
#12. A nursing student is assigned to care for a client who is 2 days post–total left hip replacement. Which observation should be reported immediately to a staff nurse?
Infection following hip replacement is serious complication that may require removal of implant .
#13. A client, who is gravida 2, para 1, ruptures her membranes spontaneously with a large amount of clear fluid. A nurse performs a vaginal examination and discovers a loop of umbilical cord in the vagina. Which immediate action should be taken by the nurse?
#14. When assessing a child for symptoms of neurogenic diabetes insipidus, what should a nurse anticipate?
#15. A client, who is gravida 1, para 0, delivered an infant at39 weeks’ gestation this morning. The client tells a nurse that she plans to breastfeed her baby and has taken a class about breastfeeding. The nurse is aware that successful breastfeeding is most dependent on:
#16. Which observation in the new-born of a mother with diabetes would require an immediate nursing intervention?
jitteriness can be indicative of hypoglycemia.
#17. In teaching a client with vision loss from glaucoma about proper lighting, a nurse knows that:
#18. A 65-year-old man with a 45-year history of smoking reports a change in his cough pattern, a non-productive cough, and generally not feeling well. The chest x-ray reveals an infiltrate. A nurse should suspect:
#19. A nurse is monitoring the progress of a gravida 3, para 1 client in active labor. Which finding should be reported to a physician immediately?
#20. The blood pressure of a 28-year-old client who is overweight and does not have diabetes is 136/78 mm Hg. Client education should include:
#21. A group of clients is attending a childbirth preparation class. A client asks a nurse how to measure the duration of the uterine contractions. Which is the best description by the nurse about the measurement of the duration of contractions?
#22. Which order written by a paediatrician for a 2-month-old infant during a well-infant visit should a nurse question?
#23. Treatment for hypertension is important in the prevention of heart failure. A nurse tells a client that the greatest decrease in blood pressure is most likely to occur with ?
#24. A client, who is gravida 3, para 1, is diagnosed with diabetes at 28 weeks’ gestation. A nurse is providing instruction about the role of insulin in managing the client’s diabetes. Which statement by the nurse is true regarding insulin needs during pregnancy?
#25. . A nursing student selects a 1/2-inch needle with which to administer a DTaP (diphtheria, tetanus, and acellular pertussis) vaccine to a 4-month-old infant. A nursing instructor’s best action would be to ?
#26. A client, who is gravida 1, para 0 at 38 weeks’ gestation, is found to have a blood pressure of 170/90 mm Hg. Which action should a nurse take first?
#27. A 12-year-old child is seen in a paediatrician’s office for a well-adolescent check-up. The adolescent’s most important vaccine status for a nurse to assess would be:
#28. A client, who fell 10 feet onto a concrete floor, presents to an emergency department. The client does not speak English. The correct action by a nurse to determine the severity of the client’s pain would be to ?
#29. The parents of a 6-month-old infant express their concerns regarding the number of vaccines their infant has already received. A nurse’s best action would be to:
#30. An undesired consequence of acute pain is the progression to a chronic pain syndrome. The correct approach by a nurse to prevent chronic pain syndrome would be to ?
#31. A 42-year-old, who is gravida 1, para 0, has a successful in-vitro fertilization and is 7 weeks pregnant. Based on the client’s history, a nurse knows the infant is at risk for:
Age of 42 ye puts her at higher risk of an infant with Down`s syndrome
#32. A client delivers a 4-pound, 8-ounce neonate at 35 weeks’ gestation. A meconium drug screen shows the presence of heroin. The neonate is admitted to the nursery with narcotic abstinence syndrome. Nursing care of the neonate should include ?
#33. A client with a known history of IV drug use is found to have acute appendicitis with perforation. Following surgery, the client reports severe pain at the surgical incision. There are no signs of abscess formation or other postoperative complications. The correct approach to manage the client’s pain would be to:
#34. The mother of a school-age child who is isolated at home with chickenpox (varicella) informs a school nurse that, “My child is miserable from the itching. What can I do?” The school nurse’s best response would be to suggest ?
#35. An 84-year-old with diabetes and left leg cellulitis is brought to an emergency department. Vital signs are: BP 132/90 mm Hg, T 99.4°F, P 95, and R 20. Blood glucose is 98. Left leg is red and swollen. The client is admitted to a nursing unit. Which order should be a priority for the nurse ?
Because low grade fever and elevated temperature are consistent with infection
#36. A client, who is gravida 4, para 0 at 39 weeks’ gestation, states, “I would like to breastfeed, but my mother-in-law told me my breasts are too small and I won’t have enough milk for my baby.” Which would be the best response by the nurse?
#37. An infant with an umbilical hernia is brought to a well-infant clinic for routine immunizations. During the visit, a nurse notes that the parent has taped the umbilical hernia down on the abdomen to flatten the protrusion. The nurse would be correct in telling the parent that?
It can produce skin breakdown and irritation
#38. A client, who is gravida 3, para 2, is asking a nurse for advice concerning her nightly leg cramps. Which response by the nurse is correct?
BCZ leg cramps are caused by low calcium in blood .
#39. A child hospitalized with measles (rubeola) cries every time a nurse enters the room and turns on the overhead light. The nurse should investigate if the child has ?
Photophobia is common side effect of measles
#40. A child is hospitalized with scarlet fever. Which food item should the nurse remove from the child’s breakfast tray?
Because scarlet fever is associated with inflamed oral cavity , so citric juices will irritate oral cavity
#41. Positioning to prevent skin breakdown is a nursing concern. Which site is at greatest risk for breakdown in this position?
#42. The most appropriate nursing intervention to encourage a child to eat who had a tonsillectomy 24 hours ago is to:
#43. A client with Sjögren’s syndrome, an autoimmune disorder in women, is scheduled for surgery. The correct nursing action would be ?
#44. A school-age child is hospitalized with mumps (parotitis). Which food item should the nurse remove from the child’s lunch tray?
#45. A client, who is gravida 5, para 4, delivered a 6-pound, 5-ounce infant 2 hours ago. The client is complaining of severe uterine cramping while breastfeeding. A nurse knows that these symptoms are most likely due to:
#46. . A child is isolated at home with whooping cough (pertussis). Which parental behaviour indicates the need for additional teaching by the nurse?
#47. A client, who is a 22-year-old primigravida, is at 38 weeks’ gestation and 9 cm of dilation. Her contractions are 2 to 4 minutes apart and her uterus palpates soft between very firm contractions. She is very irritable and screaming in pain. A nurse should instruct this client to:
#48. A client with a brain tumor has been unresponsive to verbal commands and is showing signs of abnormal motor responses. Which motor change should indicate to the nurse that a critical change in the client’s condition has occurred?
Lack of response to stimuli signals a deep coma
#49. A 30-year-old man has been recently diagnosed with Cushing’s syndrome. He asks a nurse if he will be able to continue riding off-road motorcycles. The correct response by the nurse is:
#50. A child is being prepared for a tonsillectomy. The laboratory telephones the pediatric unit and reports that the child’s prothrombin time (PT) is 14.1 seconds. The nurse’s first action should be to
#51. A client has mitral regurgitation. Where is the best place for a nurse to auscultate the associated murmur?
Murmur with mitral regurgitation is best heard at 5th intercoastal space left midclAvicular line
#52. A 92-year-old client, who recently had a below-the-knee leg amputation, is resisting attempts at rehabilitation. The most likely reason for the resistance is that the client ?
#53. A nurse prepares to discontinue the IV of a child with a low platelet count. Special precautions taken by the nurse when performing this nursing action should include:
A child with low platelet count will have bleeding tendencies .