NURS 4300 LABOUR AND DELIVERYquestions and answers 432 PGS

The labor and delivery nurse would make it a priority to assess which of the following two newborn body systems immediately after birth? Gastrointestinal and hepatic Urinary and hematologic Neurologic and temperature control Respiratory and cardiovascular The mental health nurse working with children anticipates that unrealistic expectations or a sense of failure to meet standards would cause a 10-year-old child to develop a sense of which of the following? Shame Guilt Inferiority Role confusion The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease. What piece of information would the nurse expect the mother to report? Steatorrhea Increased appetite Cheerful behavior Soft, formed stools During which of the following procedures should the labor and delivery nurse wear protective goggles in addition to gloves? Changing a soaked disposable bed pad Assisting during an amniotomy Starting an intravenous line Washing dirty instruments A client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a need for the nurse to call the physician for treatment orders? Increased gastric motility Peaked T waves on 12-lead ECG Muscle spasms Muscle weakness When evaluating the effectiveness of nursing care plans used for an anxious client, it is important to validate that the client understands that: Defense mechanisms should not be used. Some anxiety can be helpful. He should strive to never experience anxiety. He should try to avoid the fight or flight response. A nurse is discussing the home maintenance regimen with a client who has irritable bowel syndrome. Which of the following statements indicates client understanding? “I’ll take a walk after dinner each evening.” “I’ll have a cigarette after meals to relax.” “I’ll chew gum between meals to curb my appetite.” “I’ll eat a lot of fresh vegetables and fruits.” A female client state that she will not undergo any invasive testing for her “stomach pain.” The nurse explains that which of the following tests could be completed to assess the abdomen and still meet the client’s wishes? Abdominal ultrasound Barium swallow Colonoscopy CT scan with contrast Certain that her stomach pain is a symptom of cancer, a female client with somatization disorder exhibits pressured, rapid speech; elevated pulse and blood pressure; palpitations; and preoccupation with her pain, despite negative results from a gastroscopy. The nurse formulates which of the following as the priority nursing diagnosis? Pain Anxiety Hopelessness Disturbed body image The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice? Palms of the hands or soles of the feet Hard palate of oral cavity Sclera Conjunctivae A primigravida client of 16 weeks gestation states that she has not yet felt fetal movement. The nurse’s best response is: “Your fetus will move any day now. Call me in a week if you don’t feel it.” “Your fetus will begin moving at about 20 week’s gestation.” “You should have been feeling the movement already.” “Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a month.” The mother of an infant who underwent surgery to repair hypospadias asks the nurse why the infant is diapered as shown. The nurse would respond that this method of diapering will help to: Protect the urinary stent that has been put in place. Adequately measure the urinary output. Provide for maximum absorption of urine. Provide optimal protection of perineal skin from infected urine. A 56-year-old client reports to the nurse that his sleep patterns are different than when he was younger. The nurse anticipates that this client is likely to be experiencing which normal developmental pattern? 6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked decrease in Stage IV non-REM (NREM) sleep. 6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep. Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV NREM sleep. Light sleep with equal amounts of REM sleep and NREM sleep. While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which of the following actions? Notify the physician immediately. Have the client cough. Continue to monitor the system. Reposition the chest tube. Which nutritional measure would help a client with gastroesophageal reflux disease (GERD) to minimize the risk of symptoms? Eating 3 large meals a day with no snacks Using a lot of garlic to season food rather than salt Limiting intake of coffee drinks to 2 or fewer cups a day Using peppermint candies to take away the bitter taste in the mouth A client who is 20 weeks gestation is concerned about how to tell her 3-year-old son about her pregnancy. Which of the following would be the best statement when counseling this client? “If he is not pleased with the news of a new baby, you should tell him that you are disappointed in him.” “Tell him that he is going to have a lot of responsibilities in helping care for the baby.” “Try to provide extra attention to him and include him in plans for the baby.” “Tell him that he will have to stay with his grandparents when the baby is born because you will be busy with the baby.” An anxious client begins to yell and interrupt other clients. The client’s speech is rapid and pressured. What action should the nurse take? Ask the client to speak more slowly and softly. Instruct the other clients to ignore this client’s behavior. Point out to the client that the behavior is a sign of anxiety. Remind the client of the need to use good manners when talking with other people. He nurse concludes that teaching has been effective when the laboring client’s partner shouts, “She’s crowning!” as: The nurse first starts to see a little of the baby’s head. The baby’s head recedes upward between pushing contractions. The perineum is thin and stretching around the occiput. The mouth and nose are being suctioned. An 86-year-old client will be undergoing a surgical procedure. Which of the following changes would the nurse make in the informed consent process for this elderly client? Providing adequate time for the client to process the information Encouraging the family members to make the decision for the client Encouraging the client to sign immediately before the client forgets the purpose of the surgery Providing the client with reading material about the surgery and the postoperative instructions A 76-year-old woman visits the ambulatory clinic with reports of having difficulty reading and doing needlework because of visual distortions with blurring of images directly in the line of vision. The peripheral vision assessment by the nurse yields normal findings. The nurse suspects that this client is experiencing which of the following visual problems? Glaucoma Detached retina Cataracts Macular degeneration A client experiences severe nausea for up to 2 weeks following her chemotherapy treatment. Which statement indicates a need for further instruction on management of nausea? “I need to call my doctor if I lose more than 10 percent of my body weight.” “I should try to eat bland, chilled foods, and drink liquids separate from my meals.” “I need to lie down for an hour after each meal.” “I should call the doctor if my nausea doesn’t go away, to see if a different anti-emetic could provide better relief.” The nurse is caring for the client who is recovering from partial thickness burns. Which of the following breakfast options indicates client understanding of the recommended diet? Two slices of toast with butter, orange juice, skim milk Two poached eggs, hash brown potatoes, whole milk Three pancakes with syrup, two slices of bacon, apple juice One cup of oatmeal with skim milk, 1/2 grapefruit, coffee A client questions the surgical nurse about the personnel in the operating room. Which of the following initial responses by a nurse to the client’s concern is most therapeutic? “The nurses are well-qualified for the job they do.” “Have you had a bad experience in the OR?” “You’re concerned about the personnel, but you have no need to worry.” “Can you tell me about why you are interested in the personnel?” The nurse is assigned to the care of a client receiving radiation therapy for cancer. Which of the following activities needed in the care of a client receiving external beam radiation therapy could be safely delegated to an unlicensed assistive person (UAP) working on the nursing unit? Select all that apply. Observe the skin site following a treatment session. Document intake from the meal trays. Assess variations in level of fatigue during the shift. Explore how the client is coping with treatment. Assist the client to ambulate in the hall. A client with a history of heart failure suddenly exhibits shortness of breath, a respiratory rate of 30, crackles auscultated bilaterally, and frothy sputum. After telephoning the physician for medical orders, which action should the nurse delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)? Start an intravenous line and cap it with a saline lock. Monitor vital signs every 15 minutes. Administer morphine sulfate 2 mg IV push immediately. Insert a urinary catheter. An adult client with diabetes insipidus who has been taking desmopressin (DDAVP) intranasally comes to the clinic for a regularly scheduled appointment. The nurse assesses the client’s mental status and notes some disorientation and behavioral changes. Significant pedal edema is also present. What should be the nurse’s next action? Check vital signs and notify the physician. Have the client return in the morning for reevaluation. Instruct the client to limit salt intake for a few days. Suggest that the client change the route of administration to subcutaneous injections. A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurse provides what instruction to the client? “You will take a single drug such as isoniazid (INH) by mouth every day for 6 to 12 months.” “You will be on at least two drugs effective against the tubercle bacillus for three months.” “You will be on combination therapy in order to prevent development of drug resistance.” “You will need to learn to give yourself subcutaneous injections.” In assessing a hospitalized client 1 hour after receiving hydralazine (Apresoline) 20 mg PO, the nurse notes that the BP is 68/42. The client has been taking this medication for several years at home without difficulty. Which of the following factors most likely contributed to this episode of hypotension? Dose is excessive for this medication. Total intake for the previous 24 hours is 1,000 mL. Serum potassium is 5.8 mEq/L. Heart rate is 145 beats per minute. The nurse on the oncology unit has received intershift reports on 4 clients. In what order should the nurse assess these clients? Place in order of priority by clicking and dragging the options below to move them up or down. Client receiving radiation therapy who has a white blood cell (WBC) count of 4,500/mm Client receiving chemotherapy who has a platelet count of 50,000/mm Client who is crying because she has newly learned that her cancer has metastasized Client who has questions about upcoming chemotherapy A postoperative client who has an order for 5,000 units of heparin SubQ for three doses wants to know why this drug is being ordered. What information would the nurse provide to the client to best answer the question? “Heparin is used as a common medication in many clients who have surgery.” “Heparin is essential during the postoperative period to maintain adequate blood clotting levels.” “The injections will be given in the abdomen and are not usually associated with discomfort.” “Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility.” Upon physical assessment, a nurse notes that a client has visual impairment. The nurse is concerned that the client’s visual changes may affect his ability to self-administer medications. Select the nursing diagnosis below that best describes this situation. risk for ineffective therapeutic regimen management related to medication secondary to visual impairment deficient knowledge related to medication administration ineffective family therapeutic regimen management related to visual impairment ineffective coping related to lack of ability to self-administer medications A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing’s disease. Which statement by the student indicates an accurate understanding of this disorder? “Cushing’s disease results from an oversecretion of insulin.” “Cushing’s disease results from an undersecretion of corticotropic hormones.” “ Cushing’s disease results from an undersecretion of mineralocorticorticoid “Cushing’s disease results from an increased pituitary secretion of adrenocorticotropic hormone.” The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast? Puffed wheat Banana Puffed rice Cornflakes A 5-old is a family contact to the client with tuberculosis. Isoniazid (INH) has been prescribed for the client. The nurse is aware that the length of time that the medication will be taken is: 6 months 3 months 1 year 2 years Order: digoxin 25 mcg, PO, q12h. Child’s weight: 8 kg Child’s dosage: 0.006-0.012 mg/kg/day (6-12 mcg/kg/day) Available: Lanoxin 50 mcg/ml (0.05 mg/ml) Is the prescribed dose safe? How many ml should the child receive? Dose parameters: 0.048-0.096 mg/day or 48-96 mcg/day yes, 50 mcg per day ½ ml or 0.5 ml per dose A nurse is providing home care instructions to a client with a diagnosis of Addison’s disease. Which statement by the client indicates a need for further instruction? “I need to wear a Medic-Alert bracelet.” “I will need to take daily medication until my symptoms decrease.” “I need an increase dose of glucocorticoid medication during stressful minor illnesses.” “I need to purchase a travel kit that contains cortisone.” A nurse is providing home care instruction to the client with a diagnosis of Cushing, syndrome and prepares a list of instructions for the client. Which of the following should be included on the list? Select all that apply. A reminder to read labels on over-the-counter medication before purchase The signs and symptoms of hyperadrenalism The importance of maintaining regular outpatient follow-up care Instructions to take the medications exactly as prescribed The signs and symptoms of hypoadrenalism A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is: 1hour before meals 2 hours after meals With each meal and snack On an empty stomach A nurse would include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Encourage the client to consume a well-balanced diet. Instruct the client to consume a low-fat diet. Instruct the client that episodes of chest pain are expected to occur. A thyroid-releasing inhibitor will be prescribed. Provide a warm environment for the client Instruct the client that thyroid replacement therapy will be needed A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level? Before the first dose 30 minutes before the fourth dose 30 minutes after the first dose 30 minutes before the first dose The nurse is preparing to administer eye drops. Select the interventions that the nurse takes to administer the drops. Select all that apply. Put glove on. Place the drop in the conjunctival sac. Pull the lower lid down against the cheek bone. Instruct the client to squeeze the eyes shut after instilling the eye drop Instruct the client to tilt the head forward, open the eyes, and look down. Wash hands. A nurse is establishing a plan of care for a client ordered to receive antibiotic therapy. The client does not read English but is able to understand spoken English. He is of a lower income socioeconomic group. Which of the following strategies would be most appropriate to teach this client? Provide a videotape going over the information. Give the client several pamphlets and ask him to go over them with his family. Provide a teaching sheet with simple words and pictures. Arrange a quiet time to discuss the medication regimen with the client. A client with AIDS-defined disease is ordered to receive two different medications. The primary care nurse notes that he has not been taking his medications as ordered. He states that he “doesn’t like the side effects of the drugs.” Which of the following is an appropriate nursing diagnosis? knowledge deficit related to progression of the AIDS disease grieving related to diagnosis of terminal disease risk for infection related to impaired immune function noncompliance related to medication side effects and lack of knowledge A client is admitted to the hospital with a diagnostis of Addison,s disease. The nurse would assess for which of the following problems as a manifestation of this disorder? Hypotension Hirsutism Obesity Edema A client with suspected Cushing’s syndrome is schedule for adrenal venography. A nurse has provided instructions to the client regarding the test. Which statement by the client indicates a need for further instruction? “I may feel a burning sensation after the dye is injected.” “The insertion site will be locally anesthetized.” “I need to sign an informed consent.” “I will be placed in a high-sitting position for the test.” Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis? She was born at 40 weeks gestation. She had meningitis when she was 6 months old. She had physiologic jaundice after delivery. She has frequent sore throats. Meformin (Glucophage) is prescribed for a client with type 2 diabetes mellitus. A nurse tells the client that the most common side effect of the medication is: Hypoglycemia Weight gain Flushing and palpitations Gastrointestinal disturbances The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski,s sign. Which finding did the nurse observe? The client rigidly extends the arms with pronated forearms and plantar fexion of the feet. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. The client’s upper arms flexed and held tightly to the sides of the body and the legs are extended and internally rotated. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. A client with multiple sclerosis is receiving baclofen (Lioresal). A nurse assessing the client monitors for which of the following as an indication of a primary therapeutic response to the medication? Increased range of motion of all extremities Increased muscle tone and strength Decreased muscle spasms Decreased nausea A33-years-old female client is admitted to the hospital with a tentative diagnosis of Graves’ disease. Which symptom relate to the menstrual cycle would the client be most likely to report during the initial assessment? Dysmenorrhea Metrorrhagia Menorrhagia Amenorrhea Order: Hyzaar 100-25 mg/day, PO; decrease dose to 50-12.5 mg if systolic blood pressure is less than 130 mm Hg. Client’s present blood pressure is 166/86 mm Hg. Available: How many tablet(s) should the client receive with the present blood pressure result? 2 tablets of Hyzaar A nurse should correctly the therapeutic use of oxybutynin (Ditropan) as treatment for: Renal calculi Ulcerative colitis Overactive bladder Gastritis A nurse gives a dose of diazepam (Valium) to an assigned client. The most important action to be taken by the nurse before the room is: Raising the side rail on the bed Closing the curtains in the room Lowering the volume on the television set Giving the client the remote control for the television set Atorvastatin (Lipitor) has been prescribed for a client, and the client asks the nurse about the side effects of the medication. The nurse responds that a frequent side effect of this medication is: Tremors Tiredness Lethargy Headache A client who is receiving chemotherapy for breast cancer develops myelosuppression. Which of the following instructions should the nurse include in the client’s discharge teaching plan? Select all that apply. Avoid people who have received live attenuated vaccines. Avoid contact sports. Increase intake of fresh fruit and vegetables. Wash hands frequently. Avoid crowded places such as shopping malls. Treat a sore throat with over-the-counter products. A child that is 4 years old is seen for a well-child checkup. He has been regularly receiving immunizations. Select from the list below the immunization(s) the child will receive at this visit. Select all that apply. Haemophilus influenza type B vaccine Measles, mumps, rubella (MMR) vaccine Inactivated polio vaccine (IPV) Meningococcal conjugate vaccine Rotavirus vaccine Varicella vaccine Which home care instructions would the nurse provide to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. Frequent hand washing is important. The child should avoid exposure to other illnesses. The child’s immunization schedule will need revision. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). Monitor the child’s weight. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention. A nursing student is following standard precautions to prevent a hospital-acquired infection in a client. The student understands whit of the following applies to the use of standard precautions? Select all that apply. Used when working with all clients Used only when specifically indicate Applies to blood, all body fluids, secretions, and excretions. Dose not apply to those who do not have any open wounds Is designed to prevent the risk of spreading microorganisms. Order: cefaclor (Ceclor) 75 mg, PO, q8h. Child’s weight: 10 kg Child’s drug Osage: 20-40 mg/kg/day in 3 divided doses Available: How many mg should the child receive per day? Is the prescribed dose within the safe parameters? How many ml should the child receive per day? Dose parameters: 200-400 mg per day 225 mg of Ceclor per day yes, safe parameters 3 ml per dose A client asks why the oral dose of his pain medication is higher than the intravenous dose. The nurse explains that with the oral dose, some of the drug is absorbed from the GI tract and is metabolized by the liver to an inactive drug form. This reduces the amount of active drug and is called (the): • protein binding passive absorption hepatic first pass pinocytosis The nurse is monitoring a patient prescribed an aminoglycoside antibiotic for toxicity. Which of the following nursing interventions is indicated when administering this medication? Ensure that the client voids before administration. Have emergency airway equipment at the bedside. Monitor blood levels of the medication. Determine liver function before each dose. The nurse has an order to administer an I.M. injection using the Z-track technique. When carrying out this order, what should the nurse do? Insert the needle at a 45-degree angle. Wipe the needle immediately after injection. Pull the skin laterally toward the injection site. Simultaneously withdraw the needle and release the skin. A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative plan of care? Elevating the stump for the 24 hours Maintaining the client on complete bed rest Applying head to the stump as the client desires Removing the pressure dressing after the 8 hours A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy- the nurse the client is talking to at the time. This client is demonstrating which behavior? Confidentiality Splitting Empathy Gnawing Two days after undergoing a modified radical mastectomy, a client tells the nurse, “Now I won’t be sexually attractive to my husband.” Based on this statement, which nursing diagnosis is most appropriate? Anxiety Body image disturbance Altered sexuality pattern Ineffective individual coping The nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse’s actions is to avoid: A gastric ulcers. Aspiration Abdominal distension. Diarrhea For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following? Hypocalcemia Hypercalcemia Hypokalcemia Hyperkalemia A 6-year-old child with a history of varicella and aspirin intake is brought to the emergencies department. The nurse suspects Reye’s syndrome. Which assessment findings are consistent with this syndrome? A fever, decreased level of consciousness (LOC), AND impaired liver function Joint inflammation, red macular rash with a clear center, and low-grade fever Peripheral edema, fever for 5 or more days, and “strawberry tongue” Red, raised ”bull eye” rash, malaise, and joint pain How long after oral administration can the nurse expect to see digoxin, s (Lanoxin) peak effect? 2 to 5 minutes 10 to 20 minutes 30 minutes to 2 hours 2 to 6 hours A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is : Skin traction applied to a lower extremity, with the extremity suspended above the bed. Skin traction applied to a lower extremity. Skin traction applied to an extended lower extremity. Skin traction applied bilaterally to the lower extremities. When teaching a client receiving about lithium (Lithobid), the nurse should instruct the client to: Drink at least six to eight glasses of water per day and to avoid caffeine. Limit the use of salt in this diet. Discontinue medicine when feeling better. Increase the amount of sodium in this diet. The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? Exposure to sunlight will help control skin rashes. There are no activity limitations between flare-ups. Monitor body temperature. Corticosteroids may be stopped when symptoms are relieved. Which of the following describes how the nurse interprets how the nurse interprets a newborn’s Apgar score of 8 at 5 minutes? An infant who’s in good condition An infant who’s mildly depressed An infant who’s moderately depressed An infant who needs additional oxygen to improve the Apgar score. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? Altered nutrition: Less than body requirements Ineffective airway clearance Altered urinary elimination Risk for injury A nursing student is following standard precaution to prevent a hospital-acquired in a client. The student understands which of the following applies to the use of standard precaution? Select all that apply. Used when working with all clients Used only when specifically indicated A applies to blood, all body fluids, secretions, and excretions Does not apply to those who do not have any open wounds Is designed to prevent the risk of spreading microorganisms A nurse is reviewing the assessment findings and laboratory date for a client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse understands that witch of the following are associated characteristics of this disorder? Select all that apply. Hypernatremia Signs of water deficit High urine osmolality Low serum osmolality Hypotonicity of body fluids Continued release of antidiuretic hormone A nurse is caring for a client diagnosed with tuberculosis (TB). Which of the following assessments, if made by the nurse, is consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem? Select all that apply.