MATERN
The nurse is preparing a nutritional teaching plan for a client planning to become pregnant. Which foods would best prevent neural tube defects?
A. Calcium-rich snacks
B. Fortified cereals
C. Organ Meats
D. Wild salmon
B. Fortified cereals
The clinic nurse is instructing a client who is newly prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply.
A. "Apply the patch when the ship starts moving and not before."
B. "Dispose of the patch out of reach of children and pets."
C. "Make sure to remove the old patch before applying a new one."
D. "Place the patch on a hairless, clean, dry area behind the ear."
E. " Wash your hands with soap and water after handling the patch."
B. "Dispose of the patch out of reach of children and pets."
C. "Make sure to remove the old patch before applying a new one."
D. "Place the patch on a hairless, clean, dry area behind the ear."
E. " Wash your hands with soap and water after handling the patch."
The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse?
A. Client reports chest pain that is worse with deep inspiration
B. Distant heart tones and jugular venous distension
C. ECG showing ST-segment elevations in all leads
D.Pericardial friction rub auscultated at the left sternal border
B. Distant heart tones and jugular venous distension
A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit?
A. Attention span and activity level
B. Dental health and mouth dryness
C. Height/Weight and blood pressure
D. Progress with schoolwork and in making friends
C. Height/Weight and blood pressure
The primary care provider’s office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back?
A. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection
B. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration
C. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding
D. 84-year-old man with prostate cancer and spine metastasis is requesting increase pain medication
B. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration
A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply.
A. Administer a anticholinesterase drug AC
B. Administer a need for an anticholinergic drug
C. Develop a bladder training schedule
D. Encourage semi-solid food consumption
E. Teach the necessity for annual flu vaccination
A. Administer a anticholinesterase drug AC
D. Encourage semi-solid food consumption
E. Teach the necessity for annual flu vaccination
The obstetric nurse is reviewing phone messages. Which client should the nurse call first?
A. Client at 18 weeks gestation taking ceftriaxone and Reporting mild diarrhea
B. Client at 22 weeks gestation but twins who's taking acetaminophen twice a day
C. Client at 28 weeks gestation taking metronidazole and reporting dark-colored urine
D. Client at 32 weeks gestation taking ibuprofen for moderate back pain
D. Client at 32 weeks gestation taking ibuprofen for moderate back pain
The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply.
A. "Avoid drinking alcoholic beverages."
B. "Do not abruptly stop taking your phenytoin."
C. "Go to the emergency department every time a seizure occurs."
D. "Wear an epilepsy medical identification bracelet."
E. "You may need to start using a nonhormonal birth control method"
A. "Avoid drinking alcoholic beverages."
B. " Do not abruptly stop taking your phenytoin."
D. "Wear an epilepsy medical identification bracelet."
E. "You may need to start using a nonhormonal birth control method"
The nurse assess pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription?
A. Furosemide 20 mg IV push twice daily
B. Maintenance IV line of 0.9% normal saline at 85 mL/h
C. Potassium chloride 20 mEq orally twice daily
D. Sodium-restricted diet
B. Maintenance IV line of 0.9% normal saline at 85 mL/h
A recently widowed client become tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following response by the nurse are appropriate? Select all that apply.
A. "A friend of mine passed away recently. I know how hard losses can be."
B. "I see that you're upset. I will step out while you process these feelings."
C. "It may take a while, but coming to terms with loss gets easier with time."
D. "This is a difficult time. Tell me about how you have been coping."
E. "What are your thoughts about attending a grief support group? "
D. "This is a difficult time. Tell me about how you have been coping."
E. "What are your thoughts about attending a grief support group? "
A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse?
A. "How long has the oil been leaking from your head?"
B. "Let's go back to your room and look for your headband together."
C. "There is no oil coming out of your head."
D. "You are going to miss breakfast if you do not go into the dining room."
B. "Let's go back to your room and look for your headband together."
The nurse is preforming a postpartum assessment 12 hours after the prolonged vaginal delivery of a team infant. Which assessment findings should be reported to the health care provider?
A. Complaints of discomfort during fundal palpation
B. Foul-smelling lochia
C. Oral temperature 100.1 F (37.8 C)
D. White blood cell (WBC) count 24,000/mm3 (24.0 x 109/L)
B. Foul-smelling lochia
A speeding driver sustained a closed head injury in an acceleration / deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain?
A. Expressive speech
B. Light touch, hearing
C. Sense of position, graphesthesia
D. Weber tuning fork test, cranial nerve 1
A. Expressive speech
The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse?
A. Glucose 200 mg/dL (11.1 mmol/L)
B. Hematocrit 38% (0.38)
C. Potassium 3.4 mEq/L (3.4 mmol/L)
D.Troponin 0.7 ng/mL (0.7 mcg/L)
D. Troponin 0.7 ng/mL (0.7 mcg/L)
A nurse has completed teaching a client who is being discharged on lithium for bipolar disorder. Which statement by the client indicated a need for further teaching?
A. "I need to drink 1-2 liters of fluid daily."
B. "I need to have my blood levels checked periodically."
C. "I should not limit my sodium intake."
D. "I should use ibuprofen for pain relief."
D. "I should use ibuprofen for pain relief."
The nurse cares for a client following a percutaneous coronary intervention via the right groin. The client received an IV infusion of abciximab during the procedure. Which actions should the nurse implement? Select all that apply.
A. Assess invasive procedure sites for bleeding
B. Check hemoglobin and platelet count
C. Initiate a second large-bore IV line
D. Place the client on continuous cardiac monitoring
E. Report black tarry stools to the health care provider
A. Assess invasive procedure sites for bleeding
B. Check hemoglobin and platelet count
D. Place the client on continuous cardiac monitoring
E. Report black tarry stools to the health care provider
A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.
A. Blood Pressure 82/62 mm Hg
B. Crackles on auscultation
C. Distended Jugular veins
D. Pulse 120/min
E. Shoulder pain
A. Blood Pressure 82/62 mm Hg
D. Pulse 120/min
E. Shoulder pain
The nurse is assessing the cranial nerves and begins testing the facial nerve ( cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve?
A. “Close your eyes and identify the smell.”
B. “Follow my finger with your eyes without moving your head.”
C.“Look straight ahead and let me know when you can see my finger.”
D. “Raise your eyebrows, smile, and frown.”
D. “Raise your eyebrows, smile, and frown.”
A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply.
A. Bathroom scale for daily weights
B. Blood pressure cuff
C. Central line dressing change kits
D. Infusion pump
E. Intermittent urinary catheterization kits
A. Bathroom scale for daily weights
B. Blood pressure cuff
C. Central line dressing change kits
D. Infusion pump
The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicated positive progress towards recovery? Select all that apply.
A. "Drinking led to my divorce and the loss of my children."
B. "I am in control now; I drink only on special occasions."
C. "I will have no desires to drink once I get over my divorce."
D. "My focus is now on fitness training and going back to college."
E. "When cravings occur, I call my Alcoholics Anonymous sponsor."
A. "Drinking led to my divorce and the loss of my children."
D. "My focus is now on fitness training and going back to college."
E. "When cravings occur, I call my Alcoholics Anonymous sponsor."
The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures?
A. Client who had a large anterior wall myocardial infarction (MI) with subsequent heart failure
B. Client who had a mitral valvuloplasty repair
C. Client with a mechanical aortic valve replacement
D. Client with mitral valve prolapse with regurgitation
C. Client with a mechanical aortic valve replacement
A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum. Which clinical manifestation should the nurse expect?
A. Abdominal pain and low-grade fever
B. Blood pressure >140/90 mm Hg
C. High urine protein level
D. Moderate to high urine ketones
D. Moderate to high urine ketones
The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment?
A. History of Bell’s Palsy with unilateral facial droop and drooling
B. History of multiple sclerosis and reporting recent blurred vision
C. Reports unilateral facial pain when consuming hot foods
D.Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14
D. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14
The nurse is preparing to administer medications after assessing a client with a myocardial infarction. Based on the collected data, which of the following prescribed medications are appropriate for the nurse to administer? Select all that apply.
A. Aspirin
B. Atorvastatin
C. Docusate Sodium
D. Lisinopril
E. Metoprolol
Laboratory Results at 0600
Hematocrit 40% (0.40)
Hemoglobin 14.0 g/dL (140 g/L)
Platelets 200,000/mm3 (200x109/L)
Potassium 4.0 mEq/L (4.0 mmol/L)
HDL cholesterol 21 mg/dL (0.54 mmol/L)
LDL cholesterol 200 mg/dL (5.18 mmol/L)
Vital Signs at 0800
Temperature 98.4 F (36.9 C)
Blood Pressure 126/81 mm Hg
Heart Rate 49/min
Respirations 16/min
A. Aspirin
B. Atorvastatin
C. Docusate Sodium
D. Lisinopril
A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis?
A. Impaired social interaction
B. Impaired verbal communication
C. Risk for deficient fluid volume
D. Risk for impact skin integrity
C. Risk for deficient fluid volume
The nurse reviews an elderly client's medication administration record and identifies with prescriptions as having the potential for injury in the elderly? Select all that apply.
A. Amitriptyline
B. Chlorpheniramine
C. Docusate
D. Donepezil
E. Lorazepam
A. Amitriptyline
B. Chlorpheniramine
E. Lorazepam