Theglaborgandgdeliverygnursegwouldgmakegitgagprioritygtogassessgwhichgofgthegfollowinggtwognewborngbodygsystemsgi
mmediatelygaftergbirth?
GastrointestinalgandghepaticgUrina
rygandghematologicgNeurologicgan
dgtemperaturegcontrolgRespiratory
gandgcardiovascular
Thegmentalghealthgnursegworkinggwithgchildrenganticipatesgthatgunrealisticgexpectationsgorgagsensegofgfailuregtogmeetgst
andardsgwouldgcausegag10-year-oldgchildgtogdevelopgagsensegofgwhichgofgthegfollowing?
ShamegGui
ltgInferiori
ty
Rolegconfusion
Thegnursegisgtakinggagnursingghistorygfromgthegmothergofgagchildgbeinggadmittedgwithgflare-
upgofgceliacgdisease.gWhatgpiecegofginformationgwouldgthegnursegexpectgthegmothergtogreport?
SteatorrheagIncrea
sedgappetitegCheer
fulgbehaviorgSoft,g
formedgstools
Duringgwhichgofgthegfollowinggproceduresgshouldgtheglaborgandgdeliverygnursegweargprotectiveggogglesgingadditiongtog
gloves?
Changinggagsoakedgdisposablegbedgpa
dgAssistinggduringgangamniotomygS
tartinggangintravenousgline
Washinggdirtyginstruments
Agclientgwithgcancerghasgagcalciumglevelgofg11.8gmg/dL.gWhichgofgthegfollowinggsymptomsgwouldgindicategagnee
dgforgthegnursegtogcallgthegphysiciangforgtreatmentgorders?
Increasedggastricgmotilityg Peak
edgTgwavesgong12-
leadgECGgMusclegspasms
Musclegweakness
Whengevaluatinggthegeffectivenessgofgnursinggcaregplansgusedgforganganxiousgclient,gitgisgimportantgtogvalidategtha
tgthegclientgunderstandsgthat:
Defensegmechanismsgshouldgnotgbegused.
Someganxietygcangbeghelpful.
Hegshouldgstrivegtognevergexperienceganxiety.
Hegshouldgtrygtogavoidgthegfightgorgflightgresponse.
,NURSINGgTESTgBANK
Agnursegisgdiscussinggtheghomegmaintenancegregimengwithgagclientgwhoghasgirritablegbowelgsyndrome.gWhichgofgthegfo
llowinggstatementsgindicatesgclientgunderstanding?
“I’llgtakegagwalkgaftergdinnergeachgevening.”
“I’llghavegagcigarettegaftergmealsgtogrelax.”
“I’llgchewggumgbetweengmealsgtogcurbgmygappetite.”
g“I’llgeatgaglotgofgfreshgvegetablesgandgfruits.”
Agfemalegclientgstategthatgshegwillgnotgundergoganyginvasivegtestinggforgherg“stomachgpain.”gThegnursegexplainsgt
hatgwhichgofgthegfollowinggtestsgcouldgbegcompletedgtogassessgthegabdomengandgstillgmeetgthegclient’sgwishes?
Abdominalgultrasoundg
BariumgswallowgColono
scopy
CTgscangwithgcontrast
Certaingthatghergstomachgpaingisgagsymptomgofgcancer,gagfemalegclientgwithgsomatizationgdisordergexhibitsgpressur
ed,grapidgspeech;gelevatedgpulsegandgbloodgpressure;gpalpitations;gandgpreoccupationgwithghergpain,gdespitegnegat
ivegresultsgfromgaggastroscopy.gThegnursegformulatesgwhichgofgthegfollowinggasgthegprioritygnursinggdiagnosis?
Pain
Anxietyg Hopelessne
ssgDisturbedgbodygim
age
Thegnursegsuspectsgthatghepatotoxicitygisgdevelopinggingagdark-
skinnedgclientgwhogisgongangantibiotic.gIngwhatgareagofgthegbodygshouldgthegnursegassessgforgjaundice?
Palmsgofgtheghandsgorgsolesgofgthegfeet
Hardgpalategofgoralgcavity
ScleragConjunc
tivae
Agprimigravidagclientgofg16gweeksggestationgstatesgthatgsheghasgnotgyetgfeltgfetalgmovement.gThegnurse’sgbestgresp
onsegis:
“Yourgfetusgwillgmoveganygdaygnow.gCallgmegingagweekgifgyougdon’tgfeelgit.”g“
Yourgfetusgwillgbegingmovinggatgaboutg20gweek’sggestation.”
“Yougshouldghavegbeengfeelinggthegmovementgalready.”
“Yourgfetusghasgbeengmovinggforgthegpastg9gweeksgwithoutgyougfeelinggit.gYougwillgfeelgitgwithingagm
onth.”
Thegmothergofganginfantgwhogunderwentgsurgerygtogrepairghypospadiasgasksgthegnursegwhygtheginfantgisgdiaperedg
asgshown.gThegnursegwouldgrespondgthatgthisgmethodgofgdiaperinggwillghelpgto:
Protectgthegurinarygstentgthatghasgbeengputgingplace.
Adequatelygmeasuregthegurinarygoutput.gPro
videgforgmaximumgabsorptiongofgurine.
Providegoptimalgprotectiongofgperinealgskingfromginfectedgurine.
,NURSINGgTESTgBANK
Ag56-year-
oldgclientgreportsgtogthegnursegthatghisgsleepgpatternsgaregdifferentgthangwhenghegwasgyounger.gThegnurseganticipatesgth
atgthisgclientgisglikelygtogbegexperiencinggwhichgnormalgdevelopmentalgpattern?
6gtog8ghoursgofgsleepgpergnightgwithgaboutg20gtog25%gofgrapidgeyegmovementg(REM)gsleepgandgagmarked
gdecreasegingStagegIVgnon-REMg(NREM) gsleep.
6gtog8ghoursgofgsleepgpergnightgwithgaboutg20%gREMgsleepgandgagdecreasegingStagegIVgNREMgsleep.
Erraticgsleepgbecausegofgworkgschedulegwithgaboutg30%gofgREMgsleepgandgnogmarkedgdecreasegingStagegIVg
NREMgsleep.
LightgsleepgwithgequalgamountsgofgREMgsleepgandgNREMgsleep.
Whilegassessinggthegchestgtubegdrainagegsystemgofgagclient,gthegnursegobservesgagslightgrisegandgfallgingthegwaterg
levelgingthegwatergseal.gThegnursegshouldgtakegwhichgofgthegfollowinggactions?
Notifygthegphysiciangimmediately.gHa
vegthegclientgcough.
Continuegtogmonitorgthegsystem.
Repositiongthegchestgtube.
Whichgnutritionalgmeasuregwouldghelpgagclientgwithggastroesophagealgrefluxgdiseaseg(GERD)gtogminimizegthegriskgofgs
ymptoms?
Eatingg3glargegmealsgagdaygwithgnogsnacks
Usinggaglotgofggarlicgtogseasongfoodgrathergthangsalt
Limitinggintakegofgcoffeegdrinksgtog2gorgfewergcupsgagday
Usinggpeppermintgcandiesgtogtakegawaygthegbittergtastegingthegmouth
Agclientgwhogisg20gweeksggestationgisgconcernedgaboutghowgtogtellgherg3-year-
oldgsongaboutghergpregnancy.gWhichgofgthegfollowinggwouldgbegthegbestgstatementgwhengcounselinggthisgclient?
“Ifghegisgnotgpleasedgwithgthegnewsgofgagnewgbaby,gyougshouldgtellghimgthatgyougaregdisappointedginghim.
”g“Tellghimgthatghegisggoinggtoghavegaglotgofgresponsibilitiesginghelpinggcaregforgthegbaby.”
“Trygtogprovidegextragattentiongtoghimgandgincludeghimgingplansgforgthegbaby.”
“Tellghimgthatghegwillghavegtogstaygwithghisggrandparentsgwhengthegbabygisgborngbecausegyougwillgbegbusyw
ithgthegbaby.”
Anganxiousgclientgbeginsgtogyellgandginterruptgothergclients.gThegclient’sgspeechgisgrapidgandgpressured.gWhatgacti
ongshouldgthegnursegtake?
Askgthegclientgtogspeakgmoregslowlygandgsoftly.
Instructgthegothergclientsgtogignoregthisgclient’sgbehavior.g
Pointgoutgtogthegclientgthatgthegbehaviorgisgagsigngofganxiet
y.
Remindgthegclientgofgthegneedgtoguseggoodgmannersgwhengtalkinggwithgothergpeople.
Hegnursegconcludesgthatgteachingghasgbeengeffectivegwhengtheglaboringgclient’sgpartnergshouts,g“She’sgcrowning!”
gas:gThegnursegfirstgstartsgtogseegaglittlegofgthegbaby’sghead.
Thegbaby’sgheadgrecedesgupwardgbetweengpushinggcontractions.
Thegperineumgisgthingandgstretchinggaroundgthegocciput.
Thegmouthgandgnosegaregbeinggsuctioned.
, NURSINGgTESTgBANK
Ang86-year-
oldgclientgwillgbegundergoinggagsurgicalgprocedure.gWhichgofgthegfollowinggchangesgwouldgthegnursegmakeging
theginformedgconsentgprocessgforgthisgelderlygclient?
Providinggadequategtimegforgthegclientgtogprocessgtheginformation
Encouraginggthegfamilygmembersgtogmakegthegdecisiongforgthegclient
Encouraginggthegclientgtogsigngimmediatelygbeforegthegclientgforgetsgthegpurposegofgthegsurg
erygProvidinggthegclientgwithgreadinggmaterialgaboutgthegsurgerygandgthegpostoperativeginstru
ctions
Ag76-year-
oldgwomangvisitsgthegambulatorygclinicgwithgreportsgofghavinggdifficultygreadinggandgdoinggneedleworkgbecauseg
ofgvisualgdistortionsgwithgblurringgofgimagesgdirectlygingtheglinegofgvision.gThegperipheralgvisiongassessmentgbygt
hegnursegyieldsgnormalgfindings.gThegnursegsuspectsgthatgthisgclientgisgexperiencinggwhichgofgthegfollowinggvisual
gproblems?
GlaucomagDeta
chedgretinagCat
aracts
Maculargdegeneration
Agclientgexperiencesgseveregnauseagforgupgtog2gweeksgfollowingghergchemotherapygtreatment.gWhichgstatementgin
dicatesgagneedgforgfurtherginstructiongongmanagementgofgnausea?
“IgneedgtogcallgmygdoctorgifgIglosegmoregthang10gpercentgofgmygbodygweight.”
“Igshouldgtrygtogeatgbland,gchilledgfoods,gandgdrinkgliquidsgseparategfromgmygmeals.”
“Igneedgtogliegdowngforganghourgaftergeachgmeal.”
“Igshouldgcallgthegdoctorgifgmygnauseagdoesn’tggogaway,gtogseegifgagdifferentganti-
emeticgcouldgprovidegbettergrelief.”
Thegnursegisgcaringgforgthegclientgwhogisgrecoveringgfromgpartialgthicknessgburns.gWhichgofgthegfollowinggbreakfa
stgoptionsgindicatesgclientgunderstandinggofgthegrecommendedgdiet?
Twogslicesgofgtoastgwithgbutter,gorangegjuice,gskimgmilkg
Twogpoachedgeggs,ghashgbrowngpotatoes,gwholegmilkg
Threegpancakesgwithgsyrup,gtwogslicesgofgbacon,gapplegjui
cegOnegcupgofgoatmealgwithgskimgmilk,g1/2ggrapefruit,gco
ffee
Agclientgquestionsgthegsurgicalgnursegaboutgthegpersonnelgingthegoperatinggroom.gWhichgofgthegfollowingginitialgre
sponsesgbygagnursegtogthegclient’sgconcerngisgmostgtherapeutic?
“Thegnursesgaregwell-
qualifiedgforgthegjobgtheygdo.”g“Havegyoughadgagbad
gexperiencegingthegOR?”
“You’regconcernedgaboutgthegpersonnel,gbutgyoughavegnogneedgtogworry.”
“Cangyougtellgmegaboutgwhygyougareginterestedgingthegpersonnel?”
Thegnursegisgassignedgtogthegcaregofgagclientgreceivinggradiationgtherapygforgcancer.gWhichgofgthegfollowinggactivi
tiesgneededgingthegcaregofgagclientgreceivinggexternalgbeamgradiationgtherapygcouldgbegsafelygdelegatedgtogangunli
censedgassistivegpersong(UAP)gworkinggongthegnursinggunit?gSelectgallgthatgapply.
Observegthegskingsitegfollowinggagtreatmentgsession.
Documentgintakegfromgthegmealgtrays.
Assessgvariationsginglevelgofgfatiguegduringgthegshift.g
Exploreghowgthegclientgisgcopinggwithgtreatment.
Assistgthegclientgtogambulategingtheghall.