A
A multigravida client at 35-weeks' gestation is diagnosed with pregnancy-induced hypertension (PIH). Which symptom should the nurse instruct the client to report immediately?
A. Backache.
B. Constipation.
C. Blurred vision.
D. Increased urine output.
C. Blurred vision
Blurred vision, headache, visual changes, and epigastric discomfort are the most common symptoms experienced by a client with PIH and may indicate impending seizures and should be reported.
Which client finding should the nurse document as a positive sign of pregnancy?
A. Last menstrual cycle occurred 2 months ago.
B. A urine sample with a positive pregnancy test.
C. Presence of Braxton Hicks contractions.
D. Fetal heart tones (FHT) heard with a doppler.
D. Fetal heart tones (FHT) heard with a doppler
Fetal heart tones are a positive sign of pregnancy because these signs are attributed to the presence of a fetus.
A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client?
A. The client may have a bladder or kidney infection.
B. Bladder capacity increases during pregnancy.
C. During pregnancy a woman is especially sensitive to body functions.
D. The growing uterus is putting pressure on the bladder.
D. The growing uterus is putting pressure on the bladder.
Urinary frequency is a normal discomfort during the first trimester, when the enlarging uterus is still low in the pelvis. It encroaches on the bladder, reducing its capacity. Although urinary frequency is a symptom of bladder infection, it is usually accompanied by other symptoms such as burning on urination, and a kidney infection is usually accompanied by pain and fever. Bladder capacity does increase to about 1,500 mL during pregnancy, but increased capacity does not cause urinary frequency.
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?
A. The length of time each group member has resided at the nursing home.
B. A brief description of each resident's family life.
C. The age of each group member.
D. The usual activity patterns of each member of the group.
D) The usual activity patterns of each member of the group.
An older person's level of activity (D) is a determining factor in adjustment to aging as described by the Activity Theory of Aging. All information described in the options might be useful to the nurse, but the most useful information initially would be an assessment of each individual's adjustment to the aging process.
A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take?
A. Explain that anyone who speaks her language can answer her questions.
B. Provide a translator only in an emergency situation.
C. Ask a family member or friend of the client to translate.
D. Request and document the name of the certified translator.
D. Request and document the name of the certified translator.
A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented. Client information that is translated is private and protected under HIPAA rules, so enaging anyone as a translator is not the best action. Family members are not preferred translators as they may skew information and not translate the exact information.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What would be this client's expected date of delivery (EDD)?
A. November 22.
B. November 8.
C. December 22.
D. October 22.
A. November 22
November 22 is the answer. The nurse correctly applied Nägele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15+7=22).
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?
A. The client's readiness to learn.
B. The client's educational background.
C. The order in which the information is presented.
D. The extent to which the pregnancy was planned.
A. the client's readiness to learn
When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about ways to relieve morning sickness.
The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome?
A. Mother's age.
B. Amount of insulin required prenatally.
C. Degree of glycemic control during pregnancy.
D. Number of years since diabetes was diagnosed.
C. Degree of glycemic control during pregnancy.
Clients with tight glucose control and no blood vessel disease should have positive pregnancy outcomes. Risk assessment is best done by evaluating the woman's blood glucose and blood vessels, not by evaluating mother's age, number of years since diabetes was diagnosed, or the amount of insulin required prenatally.
A client at 28-weeks' gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client
A. It is not necessary to keep such a close watch on weight gain.
B. Try to exercise more because too much weight has been gained.
C. Increase the calories in your diet to gain more weight per week.
D. The weight gain is acceptable for the number of weeks pregnant.
D. The weight gain is acceptable for the number of weeks pregnant.
The normal pattern of weight gain is 2 to 4 pounds in the first trimester (by 13 weeks) and 1 pound per week after that. At 28-weeks' gestation, a weight gain between 17 and 20 pounds is acceptable.
A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration?
A. Suggest that other cultural practices be substituted by the family members.
B. Examine one's own culturally based values, beliefs, attitudes, and practices.
C. Explain to the family that multiple visitors are exhausting to the client.
D. Allow the situation to continue until a family member's action may harm the client.
B. Examine one's own culturally based values, beliefs, attitudes, and practices.
Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values to compare, recognize, and acknowledge cultural bias.
A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide?
A. Birth in the home setting is the preference for a using a midwife for delivery.
B. The pregnancy should progress normally and be considered low risk.
C. Natural child birth without analgesia is used to manage pain during labor.
D. An obstetrician should also follow the client during pregnancy.
B. The pregnancy should progress normally and be considered low risk.
A nurse midwife is an advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric client.
A client at 25-weeks' gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide?
A. This is a demonstration of the fetus's acoustical reflex.
B. The fetus can respond to sound by 24-weeks' gestation.
C. It is a coincidence the fetus responded at the same time.
D. Report the fetus's behavior to the healthcare provider.
B. The fetus can respond to sound by 24-weeks' gestation
At 24-weeks' gestation, the fetus's ability to hear loud environment sounds can illicit a startle response.
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete?
A. Palpate the pedal pulse volume.
B. Count the brachial pulse rate.
C. Measure the blood pressure.
D. Assess for a carotid bruit.
C) Measure the blood pressure.
Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure (C) should be determined. (A, B, and D) are less likely to provide data related to the client's tachycardia.
A client who is 5 foot 5 inches (165 cm) tall and weighs 200 pounds (90.9 kilograms) is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment?
A. "What is your daily calorie consumption?"
B. "What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?"
B. "What vitamin and mineral supplements do you take?"
In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral supplements. These products may impact medications used during the operative period. The nature of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's preference. Addressing long-term diet therapy is best done after surgery and recovery.
A client with type 1 diabetes has recorded in the log book blood glucose values which are within target. The client's log book lists foods high in carbohydrate content. Which laboratory test would help the nurse to better understand the client's adherence to the diabetes treatment plan?
A. Oral glucose tolerance test (GTT).
B. 24-hour urine analysis.
C. Hemoglobin A1c.
D. Fasting cholesterol.
C. Hemoglobin A1c.
The A1c measures the average blood glucose level over the past 3 months and should be used to compare with the client's diabetes self-care journal.
A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?
A. Excretes prolactin and insulin.
B. Produces nutrients for fetal nutrition.
C. Secretes both estrogen and progesterone.
D. Forms a protective, impenetrable barrier.
C. Secretes both estrogen and progesterone.
One of the early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone, necessary to maintain the pregnancy and support the embryo and fetus.
A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up.
C. Monitor vital signs every 15 minutes for the first hour.
D. Ensure the accuracy of the blood type match.
D. ensure the accuracy of the blood type match
Rationale: Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Preparing the tubing, checking the baseline hemoglobin, and monitoring vital signs should also be implemented prior to administering blood, but checking the blood type has the highest priority.
Which items should the nurse include when developing a daily meal plan for a client with hypertension?
A. Five servings of vegetables.
B. Nine servings of fruit.
C. Four servings of dairy.
D. Two servings of whole grains.
A. Five servings of vegetables
When developing a daily meal plan for a client with hypertension, the nurse should include four to five servings of vegetables in the client's meal plan as recommended by the National Institutes of Health in the Dietary Approaches to Stop Hypertension (DASH) diet. The DASH diet is recommended to prevent and control hypertension.
An adolescent with suspected bacterial meningitis is admitted after a lumbar puncture specimen is collected and sent to the laboratory. Which action is most important for the nurse to implement next?
A. Administer pain medication.
B. Collect blood for serum electrolytes.
C. Insert an indwelling urinary catheter.
D. Place on droplet precautions.
D. Place on droplet precautions.
Meningococcal meningitis, diagnosed by culture of cerebrospinal fluid, is transmitted via droplet transmission. Until laboratory results confirm the etiological organism, the client (pediatric or adult) with meningococcal meningitis should be placed on droplet precautions until 24 hours of appropriate antibiotic therapy is completed.
An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent motion sickness while on a cruise. Which information should the nurse provide to the client?
A. Apply the patch at least 4 hours prior to departure.
B. Change the patch every other day while on the cruise.
C. Place the patch on a hairless area at the base of the skull.
D. Drink no more than 2 alcoholic drinks during the cruise.
A) Apply the patch at least 4 hours prior to departure.
Scopolamine, an anticholinergic agent, is used to prevent motion sickness and has a peak onset in 6 hours, so the client should be instructed to apply the patch at least 4 hours before departure (A) on the cruise ship. The duration of the transdermal patch is 72 hours, so (B) is not needed. Scolopamine blocks muscarinic receptors in the inner ear and to the vomiting center, so the best application site of the patch is behind the ear, not at the base of the skull (C). Anticholinergic medications are CNS depressants, so the client should be instructed to avoid alcohol (D) while using the patch.
An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?
A. Leukocytosis and febrile.
B. Polycythemia and crackles.
C. Pharyngitis and sputum production.
D. Confusion and tachycardia
D. Confusion and tachycardia
The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?
A. 15 minutes before and 15 minutes after the next dose.
B. One hour before and one hour after the next dose.
C. 5 minutes before and 30 minutes after the next dose.
D. 30 minutes before and 30 minutes after the next dose.
C) 5 minutes before and 30 minutes after the next dose.
Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.)
A. Set the infusion pump to infuse the albumin within four hours.
B. Compare the client's blood type with the label on the albumin.
C. Assign a UAP to monitor blood pressure q15 minutes.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assess for increased bleeding after administration.
A, D, E, F
Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. Albumin administration does not require blood typing. Vital signs should be monitored periodically to assess for fluid volume overload. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While monitoring for bleeding because of the increased blood volume and blood pressure.
An 6-year-old child receives a prescription for the antibiotic tetracycline. Which side effect should the nurse review with the prescriber?
A. Nephrotoxicity and ototoxicity with long term use.
B. Enamel hypoplasia and discoloration in developing teeth.
C. Skin rash last time ampicillin was prescribed.
D. Cross-hypersensitivity to penicillins.
B. Enamel hypoplasia and discoloration in developing teeth.
Tetracyclines cause enamel hypoplasia and tooth discoloration in children whose permanent teeth that are still developing and have not erupted.
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
A. Frequency of emesis in the last 8 hours.
B. Serum BUN and creatinine levels.
C. Current blood sugar level.
D. Appearance of the stool.
B. Serum BUN and creatinine levels
Regardless of a client's age, adequate renal function must be present before adding potassium to IV fluids