PN~CD~Questions~1701-1800 Comprehensive Review CD Questions 1701-1800

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{COMP: <AQ> questions: 1738-1742, 1746, 1748, 1776, 1778; formulas: 1738, 1741, 1742, 1746, 1748.} 1701. A nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which of the following first? 1. Temperature 2. Urine output 3. Respiratory status 4. PCA pump Answer: 3 Rationale: Morphine sulfate depresses respirations. The nurse monitors the client’s respiratory status closely. Although the incorrect options may be a component of the data collection process, option 3 identifies the priority nursing action. Test-Taking Strategy: Note the key word first. Use the ABCs—airway, breathing, and circulation—to guide you to the correct option. Review the priority nursing interventions when caring for a client receiving morphine sulfate if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 734. 1702. A nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which action? 1. Check the placement of the tube 2. Check the last time that medications were given 3. Check the client’s temperature 4. Warm the feeding to 103° F Answer: 1 Rationale: To prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or place the head of the bed elevated at least 30 degrees. Before the feeding, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Formulas are administered at room temperature. Options 2 and 3 are not directly related to the issue of the question. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. To prevent the complication of aspiration when feeding a client with an NG tube, the nurse would first

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assess accurate placement of the tube. Review the principles related to NG tube feedings, if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1403, 1408. 1703. A client receiving total parenteral nutrition (TPN) is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position? 1. Supine 2. Prone 3. High-Fowler’s 4. Left side in Trendelenburg’s Answer: 4 Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg’s position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. Options 1, 2, and 3 identify incorrect positions. Test-Taking Strategy: Use the process of elimination and note the key word immediately. Eliminate options 1 and 2 first because they are both flat positions. From the remaining options, think about the principles of gravity and the anatomy of the cardiopulmonary system to direct you to option 4. Review the priority nursing actions when an air embolism occurs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1315. 1704. A nurse is checking a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the site. The nurse should do which of the following first? 1. Check for a blood return 2. Remove the IV 3. Apply a warm compress 4. Measure the area of infiltration Answer: 2 Rationale: Blanching, coolness, and edema of the IV site are all classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the first action by the nurse is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if

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the infiltrated solution is not damaging to the surrounding tissue. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed. Test-Taking Strategy: Note the key word first. Although all of the options may be appropriate, it is necessary to prioritize. The signs presented in the question identify infiltration. Infiltration indicates that the IV needs to be removed. Review the signs of infiltration and the appropriate initial interventions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1189. 1705. A client has just been treated with cardioversion. The nurse should assess which of the following first? 1. Status of airway 2. Oxygen flow rate 3. Level of consciousness 4. Blood pressure Answer: 1 Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority. Test-Taking Strategy: Note the key word first. Use the ABCs—airway, breathing, and circulation—to direct you to option 1. Review the priority nursing responsibilities following cardioversion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 577. 1706. A nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which of the following? 1. Stimulate the perioral cavity with a finger 2. Clap the hand or slap on the mattress 3. Stimulate the pads of the hands by firm pressure 4. Stimulate the ball of the foot by firm pressure Answer: 2 Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar reflex is elicited by

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stimulating the palm of the hand by firm pressure, and the plantar reflex is elicited by stimulating the ball of the foot by firm pressure. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 are similar and should be eliminated first. From the remaining options, focusing on the issue of the question, the Moro reflex, will assist in directing you to option 2. Review assessment of neonatal reflexes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 700. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 523, 524. 1707. A nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which of the following first? 1. Peripheral pulses 2. Temperature 3. Heart rate 4. Blood pressure (BP) Answer: 1 Rationale: The client who receives circumferential burns to the extremities is at risk for impaired peripheral circulation. The priority assessment would be to check for peripheral pulses to ensure that adequate circulation is present. Although the temperature, heart rate, and BP would also be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses. Test-Taking Strategy: Use the process of elimination. Focus on the key words first and circumferential burns of both legs to assist in directing you to the correct option. If you had difficulty with this question or are unfamiliar with the priority assessment in a client who sustained a circumferential burn of an extremity, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing References: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1629. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 525. 1708. A nurse is preparing to get a quadriplegic client out of bed into a chair. The nurse places which of the following items on the seat of the chair as the best device for pressure relief? 1. Water pad 2. Plastic lined absorbent pad 3. Pillow

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4. Air ring Answer: 1 Rationale: The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client’s weight on the device. These include foam, water, gel, or alternating air pads. A plastic lined pad absorbs moisture, but provides no pressure relief. A pillow provides cushion, but does not redistribute weight equally. An air ring relieves pressure in some spots, but causes pressure in others by its design. Test-Taking Strategy: The key words in the question are pressure relief and quadriplegic. Eliminate option 2 first because it does not provide any protection against pressure. Eliminate option 4 next because it redistributes weight unequally under this client. Choose correctly from the remaining options by recalling that the water pad will redistribute weight, and the pillow will not. Review the devices that provide pressure relief to prevent skin breakdown if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 279. 1709. A nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse if the procedure will be painful. The nurse should make which response to the client? 1. “No it is not painful.” 2. “You will receive a general anesthetic.” 3. “A local anesthetic will be given.” 4. “You will be heavily medicated before the procedure.” Answer: 3 Rationale: A local anesthetic is used to anesthetize the skin and subcutaneous tissue to minimize tissue discomfort with needle insertion. The client will feel some pain briefly when the sample is aspirated out of the marrow. Options 1, 2, and 4 are incorrect statements. Test-Taking Strategy: Focus on the diagnostic test and how this test is performed. Knowing that the procedure may be performed at the bedside will assist in eliminating options 2 and 4. Knowing that the procedure is invasive will assist in eliminating option 1. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 176. 1710. A nurse is administering intramuscular iron to an assigned client. The nurse

beet greens. Use a Z-track method for administration 2. p. turnip tops.). but before the medication is given. Williams’ basic nutrition & diet therapy (11th ed. S. carrots. A nurse has conducted dietary teaching with the client who has iron deficiency anemia. St. The site should not be massaged after injection. Focusing on the issue.PN~CD~Questions~1701-1800 - 6 should do which of the following to prevent skin staining around the injection site? 1. Test-Taking Strategy: Focus on the client’s diagnosis.. blackstrap molasses. such as the arms or thighs. Administer the injection in the thigh 4. The best sources of dietary iron are red meat. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Lewis. 711. Review foods high in iron if you had difficulty with this question. Other good sources of iron are kidney beans. and apricots. Louis: Mosby. Louis: Mosby. 1711. will assist in eliminating options 2 and 3. Review the procedure for the administration of iron if you had difficulty with this question. raisins.. Refined white bread 2. and oysters. pp. (2005). Recalling the foods high in iron will direct you to option 4. liver. (2004). Massage the site well after injection Answer: 1 Rationale: Proper technique for administering iron by the intramuscular route includes using a Z-track technique and changing the needle after drawing it up.). Kidney beans Answer: 4 Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. 142-143. Heitkemper. Medical-surgical nursing: Assessment and management of clinical problems (6th ed. M. to prevent skin staining. Use principles of medication administration by the intramuscular route and focus on the medication being administered to direct you to option 1. egg yolk. The nurse determines that the client understood the information if the client states to increase intake of which of the following foods? 1. and other organ meats. The medication should be given in the upper outer quadrant of the buttock and not in exposed areas. Egg whites 3. kale. S. St. Test-Taking Strategy: Use the process of elimination. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Nix. spinach. whole-wheat bread. . Pineapple 4. & Dirksen. Administer the injection in the nondominant arm 3. S.

A. N. dizziness.PN~CD~Questions~1701-1800 - 7 1712. Saunders. Test-Taking Strategy: Knowledge about the clinical manifestations of metabolic alkalosis will direct you to option 2. A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. will direct you to option 2. Stage 3 pressure ulcer 4. Decreased respiratory depth and rate and dysrhythmias 3. restlessness. Remember that in this disorder the respiratory rate and depth decrease. (2003). vomiting. and 4 are not associated with metabolic alkalosis. Test-Taking Strategy: Use the process of elimination and knowledge of the characteristics associated with each stage of pressure ulcers. nausea. Introduction to medical-surgical nursing (3rd ed.). The nurse checks this client for which signs and symptoms characteristic of this disorder? 1. Drowsiness. A nurse is checking the skin on a client who is immobile and notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. Tachypnea.. & Maebius.. N. Stage 2 pressure ulcer 3.B. blister. 2. Philadelphia: W. 1713. The nurse documents these findings as a: 1. There is partial-thickness skin loss of the epidermis or dermis. numbness and tingling in the extremities. Review the clinical manifestations of metabolic alkalosis if this question was difficult. hypocalcemia. and paresthesias Answer: 2 Rationale: The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth. p. twitching in the extremities. 273. Introduction to medical-surgical nursing (3rd ed. review the characteristics associated with each stage of pressure ulcers. Philadelphia: W. p. the skin is not intact. A deep craterlike appearance occurs in stage 3. Stage 1 pressure ulcer 2. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton. partial-thickness skin loss of the upper layer of the skin. and dysrhythmias. Focusing on the description in the question. headache. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton. or shallow crater. and tachypnea 2. diarrhea. hypokalemia.B. & Maebius.). A. Options 1. 165. Disorientation and dyspnea 4. and sinus tracts develop in stage 4. Stage 4 pressure ulcer Answer: 2 Rationale: In a stage 2 pressure ulcer. . The ulcer is superficial and may characterize as an abrasion. (2003). The skin is intact in stage 1. If you had difficulty with this question. Saunders.

The physician prescribes diphenhydramine (Benadryl) to be administered before the administration of the transfusion.. 2.8 g/dl is at severe risk for malnutrition. Philadelphia: W. This type of transfusion reaction is prevented by pretreating the client with an antihistamine. however. The nurse reviews the client’s laboratory results and determines that the client is at risk for severe malnutrition if the albumin level report indicates which critical level? 1. & Berger.PN~CD~Questions~1701-1800 - 8 1714. Promote bone marrow absorption Answer: 1 Rationale: An urticaria reaction is characterized by a rash accompanied by pruritus.8 g/dl Answer: 4 Rationale: The serum albumin level is a critical indicator of the need for TPN. 5. The nurse determines that this medication has been prescribed to: 1. Prevent a rash and pruritus 2. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Chernecky. Saunders.4 to 5 g/dl will direct you to option 4.9 g/dl 4. 4. A nurse is assisting in monitoring a client who may be started on total parenteral nutrition (TPN). Recalling the classification of diphenhydramine and that it is an antihistamine will assist in directing you to option 1. B.B. p. and 4 are incorrect statements.5 g/dl 3. Test-Taking Strategy: Note the key words critical level. Prevent a fever 3. C. Promote sedation 4. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills . One unit of packed red blood cells has been prescribed for a client postoperatively because the client’s hemoglobin level is low. 2. The client whose albumin level is 2. Laboratory tests and diagnostic procedures (4th ed. and 3 identify normal albumin levels. Review blood transfusion reactions and their management if you had difficulty with this question. Knowing that the normal albumin level is 3. (2004). 3. 1715. 3. Acetaminophen (Tylenol).0 g/dl 2. 148. Options 2. such as diphenhydramine.4 to 5 g/dl. Options 1. may be prescribed before the administration to assist in preventing an elevated temperature. The normal serum albumin level in the adult is 3.). Test-Taking Strategy: Focus on the medication. Review this laboratory test if you had difficulty with this question.

and 3 are incorrect for these reasons.. & Hogan. pp. Which of the following actions should the nurse take next? 1. & Potter. p. Saunders. and the client is still passing brown liquid stool. Continue to administer the enemas until the stool is clear 3. Test-Taking Strategy: Use the process of elimination. “I need to collect the urine in the cup just after I start to urinate. 701-702. A nurse is providing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure? 1. Excessive enemas could cause fluid and electrolyte depletion. & Kizior.). 1717.PN~CD~Questions~1701-1800 - 9 Reference: Hodgson.” 4. Philadelphia: W. Notify the registered nurse (RN) Answer: 4 Rationale: Up to three enemas may be given when there is an order for enemas until clear.” The nurse has administered three enemas. M. 1716. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Harkreader. R. Wait 30 minutes. Saunders..B. Options 1. P. The specimen should be sent to the laboratory as soon as possible and not allowed to stand.). Saunders nursing drug handbook 2005. A physician has written an order for a preoperative client to have “enemas until clear. Use basic principles related to hygiene to eliminate option 2. The client should begin the flow of urine. (2004). 2. B.B. Clinical nursing skills & techniques (5th ed. Louis: Mosby. the nurse notifies the RN who will then call the physician (or act based on agency policy). the client should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. If more than three are necessary. A.” 2. “I should douche just before I collect the specimen. H. St. use knowledge of basic bowel elimination procedures and . Perry. “I need to bring the specimen to the laboratory within 48 hours after I collect it..” Answer: 3 Rationale: As part of correct procedure.A. Test-Taking Strategy: Use the process of elimination. “I should cleanse the perineum from back to front. 333. Fundamentals of nursing: Caring and clinical judgment (2nd ed. and then administer another enema 2. 1151. (2004). check the client’s electrolyte levels. If this question was difficult. Encourage the client to drink clear liquids and administer another enema in 1 hour 4. review this procedure. Eliminate options 1. It is not normal procedure to douche before collecting the specimen. collecting the sample after starting the flow of urine. Improper specimen handling can yield inaccurate test results. and 3 because they are similar. (2005). p. 2. Recalling that the specimen should be brought to the laboratory after collection will assist in eliminating option 4. Philadelphia: W.” 3. From the remaining options. Also. noting the name of the type of sample “midstream” will direct you to option 3.

Perry. St.PN~CD~Questions~1701-1800 - 10 consider the physiological effects that can occur with enema administration.35. This will assist in directing you to the correct option. 165. has deep. p. (2003). Option 1 reflects a metabolic acidotic condition and describes the blood gas values as indicated in the question. M. (2004). N.). remember that the pH is elevated with alkalosis and low in acidosis. p. 1719. Introduction to medical-surgical nursing (3rd ed. and the HCO 3 is less than 22 mEq/L. Clinical nursing skills & techniques (5th ed.). H. & Hogan. Saunders. Respiratory acidosis 4. Metabolic alkalosis 3.35. Therefore options 3 and 4 are eliminated first. Review the procedure for administering enemas if you had difficulty with this question.. & Potter. C.B. whereas alkalosis is defined as a pH greater than 7. Fundamentals of nursing: Caring and clinical judgment (2nd ed. Philadelphia: W. Respiratory alkalosis Answer: 1 Rationale: Acidosis is defined as a pH of less than 7.. Laboratory tests and diagnostic procedures (4th ed. Test-Taking Strategy: Remember that in a metabolic imbalance you will find that the pH and the HCO 3 move in the same direction.A. 751. Respiratory acidosis is present when the PCO2 is greater than 45. Chernecky.). P. whereas respiratory alkalosis is present when the PCO2 is less than 35.B. HCO 3 of 14 mEq/L. PO2 86 of mm Hg.). 681. Next. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Linton. whereas metabolic alkalosis is present when the pH is greater than 7. p. A. p. Saunders. Saunders. This client’s ABG are consistent with metabolic acidosis. Review the steps related to reading blood gas values if you had difficulty with this question. & Berger. A client comes to the emergency room with lethargy.B. A. (2004). Metabolic acidosis is present when the pH is less than 7. B. Philadelphia: W. The client’s arterial blood gases (ABG) results are: pH of 7. & Maebius.. Philadelphia: W. Louis: Mosby. Metabolic acidosis 2.45. and a fruity odor to the breath. PCO2 of 34 mm Hg. 245. and the HCO 3 is greater than 27 mEq/L. (2004). Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader.25. A client wishes to donate blood for a family member and asks the nurse about the − − − − . The nurse interprets that the client has which acid-base disturbance? 1. regular respirations.. 1718.45.

PN~CD~Questions~1701-1800 - 11 procedure for identifying compatibility. but does not determine compatibility. Saunders. This test is used in addition to the ABO typing. Test-Taking Strategy: Note the relation of the word “bradypnea” in the question and the words “abnormally slow” in option 4. Indirect Coombs’ test Answer: 4 Rationale: The indirect Coombs’ test detects circulating antibodies against red blood cells (RBCs). . The direct Coombs’ test is used to detect idiopathic hemolytic anemia. a routine hematological screening test. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Chernecky. Eosinophil and monocyte counts are part of a complete blood count. 2.B. Regular but interspersed with periods of apnea 3. p. Eliminate options 1. and is the “screening” component of the order to “type and screen” a client’s blood. Respirations that cease for a number of seconds are identified as apnea. N. by detecting the presence of autoantibodies against the client’s RBCs. A nurse is monitoring a client for bradypnea. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton. Review the characteristics of these types of respirations if this question was difficult. Eosinophil count 2. a complete blood count. Which of the following is characteristic of this respiratory pattern? 1. and 3 because they are part of routine lab work.. regular. Laboratory tests and diagnostic procedures (4th ed. C. Abnormally deep. Philadelphia: W.). 412. Kussmaul’s respirations are abnormally deep. Monocyte count 3. Philadelphia: W. p. Red blood cell count 4.B. 472. Saunders. & Maebius.). Introduction to medical-surgical nursing (3rd ed. B. A. (2004). Review the tests identified in the options if you had difficulty with this question. Labored and increased in depth and rate 2. Test-Taking Strategy: Use the process of elimination. The nurse tells the client that which test will be done to test compatibility? 1. A red blood cell count is also part of a complete blood count and determines the number of circulating red blood cells. with increased rate 4. which is normally done to determine blood type. regular. Hyperpnea is characterized as respirations that are labored and increased in depth and rate. & Berger. and increased in rate.. 1720. Regular but abnormally slow Answer: 4 Rationale: Bradypnea is characterized by respirations that are regular but abnormally slow. (2003).

PN~CD~Questions~1701-1800 - 12 1721. and twitches are seen in a client with hypomagnesemia. If you had difficulty with this question. A 3-mL syringe taken from the medication supply area is not used.0 mEq/L is experiencing hypermagnesemia. Obtains a 3-mL syringe from the medication supply area 4.6 mg/dl. Tetany Answer: 2 Rationale: The normal magnesium level is 1. and the client is being treated for the magnesium imbalance. Records the percent of oxygen on the requisition 3. and loss of consciousness. such as body temperature and amount of oxygen in use. Recalling that a heparinized syringe is used to prevent clotting of the blood will direct you to the correct option. review the signs found in magnesium imbalances. The nurse avoids doing which of the following to properly obtain and send the specimen? 1. B. Records the client’s temperature on the requisition 2. Eliminate options 1.). Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Black. & Berger. A nurse has assisted with obtaining a set of arterial blood gases (ABG). Twitches 4. Places the specimen on ice Answer: 3 Rationale: The specimen is drawn into a heparinized syringe to prevent clotting of the blood. Loss of deep tendon reflexes 3. Saunders. This word indicates a false-response question and that you need to select the incorrect action. A nurse is caring for a client whose magnesium level is 4. J. 1722.. Test-Taking Strategy: Note the key word avoids. (2004). 249. C. respiratory insufficiency. hypotension. The requisition is fully completed identifying pertinent client information. Laboratory tests and diagnostic procedures (4th ed. The other options are correct. loss of deep tendon reflexes. J. Philadelphia: W.B. The specimen should be placed on ice after it is obtained. Muscular excitability 2.. and 4 because they are similar in that they all reflect neurological excitability.6 to 2.B. drowsiness and lethargy. & Hawks. A client with a magnesium level of 4. Test-Taking Strategy: Use the process of elimination. Philadelphia: W.0 mg/dl. Signs include neurological depression. tachycardia. 244. Review the procedure for obtaining ABG if you had difficulty with this question. Saunders. muscular excitability. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Chernecky. 3. p. .). (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed. p. Tetany. The nurse interprets that the electrolyte imbalance is resolving if the client has relief from which sign or symptom? 1.

B. Respiratory acidosis 4. Level of Cognitive Ability: Analysis . Note that the client condition described in the question is a client with a gastrointestinal disorder. Saunders. tetany. Respiratory alkalosis Answer: 1 Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions.). vertigo. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy? 1. A client underwent creation of an ileostomy 2 days ago. p. such as diarrhea or the creation of an ileostomy. and 4. such as tingling of the fingers and toes. review the clinical manifestations associated with respiratory alkalosis. With this in mind. you may eliminate options 2 and 4 first because alkaline secretions are lost in a client with an ileostomy. This will direct you to choose the metabolic acidosis over the respiratory acidosis. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. A review of the arterial blood gases results indicate that the client is experiencing respiratory alkalosis. 162. or hyperchloremia. Hypercalcemia 4. light-headedness. hypokalemia. paresthesia. Test-Taking Strategy: Begin to answer this question by recalling that intestinal fluids are alkaline. and convulsions.PN~CD~Questions~1701-1800 - 13 1723. headache. Hypokalemia 3. Hyperchloremia Answer: 2 Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth. hypocalcemia. Philadelphia: W. Metabolic alkalosis 3. The client with an ileostomy is not at risk for developing the acid-base disorders identified in options 2. Clinical manifestations do not include hyponatremia. If you had difficulty with this question. 1724. review the causes of metabolic acidosis. A nurse is caring for an adult client with respiratory distress syndrome. The nurse would then evaluate the results of serum electrolytes to see if which electrolyte imbalance is present? 1. & Maebius. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Linton. 3. Introduction to medical-surgical nursing (3rd ed. N. mental status changes. A. Hyponatremia 2. hypercalcemia. Remember that hypokalemia occurs in respiratory alkalosis. These fluids may be lost from the body before they can be reabsorbed with conditions. Metabolic acidosis 2. Test-Taking Strategy: Use the process of elimination and knowledge of the signs and symptoms of respiratory alkalosis to answer the question.. (2003). If this question was difficult.

A nurse is caring for a client with liver disease. p. The extinguisher should then be aimed at the base of the fire. 165. Pulling the pin on the fire extinguisher 3. S = Squeeze the handle. The handle of the extinguisher is then squeezed. & Maebius.6 to 10.. A =Aim at the base of the fire. Although the nurse needs to be cautious when using an extinguisher.). 991. Fundamentals of nursing (6th ed.PN~CD~Questions~1701-1800 - 14 Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton.. & Perry. Philadelphia: W. The nurse prepares to use the fire extinguisher by first: 1. and obtains a fire extinguisher to extinguish the fire. If you had difficulty with this question. Test-Taking Strategy: Use the process of elimination.B. 1726. S = Sweep from side to side to coat the area evenly. A. and the fire is extinguished by sweeping from side to side to coat the area evenly. Introduction to medical-surgical nursing (3rd ed. p. review the appropriate use of a fire extinguisher. (2003). Remember the mnemonic PASS to prioritize in the use of a fire extinguisher. St. P = Pull the pin. Eliminate options 3 and 4 first because these actions would delay the process of extinguishing the fire. P. it is not necessary to don gloves or a mask. Additionally. the pin is pulled first. these actions would delay the process of extinguishing the fire.0 mg/dl. The nurse checks to see that which of the following medications is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance? 1. A nurse enters a laundry room to empty a bag of dirty linens and discovers that there is a fire in the laundry room. Calcium gluconate 4. Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter. To use the extinguisher. Level of Cognitive Ability: Application Client Needs: Safe. Vitamin D 3. N. Obtaining a mask and putting it on before using the extinguisher Answer: 2 Rationale: A fire can be extinguished by smothering it with a blanket or by the use of a fire extinguisher. Saunders. (2005). and the client’s serum calcium level is 13. Calcium chloride Answer: 1 Rationale: The normal serum calcium level is 8.0 mg/dl. Squeezing the handle on the extinguisher 2. Laboratory studies are performed. 1725. The nurse activates the alarm. Louis: Mosby. Calcium gluconate and calcium chloride are used to treat . closes the laundry room door. Calcitonin (Calcimar) 2. This client is experiencing hypercalcemia.). A. Obtaining a pair of gloves and putting them on before touching the extinguisher 4.

Philadelphia: W. Gloves and a gown Answer: 1 Rationale: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood.. review Transmission Based Precautions. Level of Cognitive Ability: Application Client Needs: Safe. the nurse notes that the client has a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Introduction to medical-surgical nursing (3rd ed. body fluids. and shoe protectors 4. St. contact precautions require the use of gloves and a gown to be worn if direct client contact is anticipated. (2003). With this knowledge. and excretions. A. Use the process of elimination in determining the necessary items required to care for this client. and goggles 2. Gloves.. The nurse gathers supplies before entering the client’s room and obtains which of the following necessary protective items? 1. decreases the plasma calcium level by increasing the incorporation of calcium into the bones. In hypercalcemia. 783. gown. Clinical nursing skills & techniques (5th ed. 941. you can eliminate options 3 and 4 because you would not administer medication that would further increase the calcium level. pp. From the remaining options. and frequent suctioning. Test-Taking Strategy: Begin to answer this question by determining that the client is experiencing hypercalcemia. p. P.B. & Potter. A. N. Saunders.). (2004). thus keeping it out of the serum. Gloves. review the treatment for hypercalcemia. If you had difficulty with this question. Louis: Mosby. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Linton. Gloves and goggles 3. remember that excessive vitamin D is a causative factor of hypercalcemia. 930. Test-Taking Strategy: Note the key words contact precautions. The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. Calcitonin. irrigation. Shoe protectors are not necessary.PN~CD~Questions~1701-1800 - 15 tetany that results from acute hypocalcemia. In addition. Mild exercise . gown. secretions. A nurse is assigned to care for a client on contact precautions. A nurse is doing discharge teaching with a client who has sickle cell disease.). If you had difficulty with this question. 1727. The nurse instructs the client to avoid which of the following factors that could precipitate a sickle cell crisis? 1. Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry. & Maebius. a thyroid hormone. On review of the client’s record. large doses of vitamin D should be avoided. 1728.

. Finally the client should avoid being in areas of high altitude or flying in nonpressurized aircraft because of lesser oxygen tension in these areas. which can increase metabolic demand and cause dehydration. Saunders. Philadelphia: W..PN~CD~Questions~1701-1800 - 16 2. Test-Taking Strategy: Use the process of elimination noting the key word avoid. N. Philadelphia: W. (2003). Test-Taking Strategy: To answer this question correctly. Introduction to medical-surgical nursing (3rd ed.). A.B. If this question was difficult. Warm weather and mild exercise does not need to be avoided. p. & Maebius. Saunders. A client is at risk for developing hypocalcemia. Pain 3. The symptoms listed in the other options are not part of the clinical picture.B. Warm weather 4. Blurred vision Answer: 2 Rationale: Sickling crisis often causes pain in the bones and joints. review the clinical manifestations associated with sickle cell crisis. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton. Recalling the precipitating factors of sickle cell crisis will direct you to option 4. 525. but the client should take measures to prevent dehydration during these conditions. N. you must be familiar with the signs and symptoms of sickle cell crisis. Fluids are important to prevent dehydration. Review these precipitating factors if you had difficulty with this question. A. Diarrhea 4. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted in the client? . & Maebius. The client should also avoid dehydration from other causes. 524. A client is admitted to the hospital with sickle cell crisis. Fluid overload 3. Pain is a classic symptom of the disease and may require large doses of narcotic analgesics when it is severe. accompanied by joint swelling. Recalling that the primary treatment of sickle cell crisis focuses on the administration of fluids and on management of pain will enable you to eliminate the incorrect options. precipitating a sickle cell crisis. Introduction to medical-surgical nursing (3rd ed. The nurse checks this client for which frequent symptom of the disorder? 1. 1730. p. 1729. Infection Answer: 4 Rationale: The client should avoid infections. Bradycardia 2. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton.). (2003).

Positive Trousseau’s sign 4. Options 1. and 4 are signs of hypercalcemia. B. Additional signs of hypocalcemia include a decreased heart rate. These words indicate a false-response question and that you need to select the incorrect client statement. memory impairment. The nurse determines that the client needs additional instructions if the client verbalized to: 1. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen. Review oxygen safety measures if you had difficulty with this question. Increased heart rate 3. Keep the oxygen concentrator as close to the room wall as possible 2. A nurse has instructed a client in safety measures while using oxygen in the home. The client should follow the oxygen prescription exactly. St.). hypotension. This could result in fire and injury to the client. which could result from heat in the form of flames or sparks. Louis: Mosby. 1731. Test-Taking Strategy: Note the key words needs additional instructions. and oxygen vendor available. hyperactive bowel sounds. Level of Cognitive Ability: Comprehension . From the remaining option. (2003). & Kockrow. Forbid smoking or open flames within 10 feet of the oxygen source Answer: 1 Rationale: The oxygen concentrator is kept slightly away from the walls and corners to permit adequate airflow. 2.. 470. and teaching the client signs and symptoms requiring emergency care. hyperactive reflexes. irritability. p. Test-Taking Strategy: Use the process of elimination. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. and a positive Trousseau’s or Chvostek’s sign. E. tetany. General principles regarding prescriptions will assist in eliminating option 3. This will assist in eliminating options 2 and 4. Adult health nursing (4th ed. Eliminate options 1 and 2 first because they are similar in that they both reflect an increase in relation to cardiovascular function. Follow the oxygen prescription exactly 4. Increased blood pressure 2. Therefore a straight razor is used for shaving. recall that the major hazard associated with oxygen is ignition. From the remaining options. Use a straight razor to shave while wearing the oxygen 3. having telephone numbers for the physician. muscle cramps. insomnia. seizures. Other measures include keeping the source out of direct sunlight. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use. nurse. increased neuromuscular excitability. Hypoactive bowel sounds Answer: 3 Rationale: Signs of hypocalcemia include paresthesias. and anxiety. Review the findings noted in hypocalcemia if you had difficulty with this question. it is necessary to know that a positive Trousseau’s sign is an indication of hypocalcemia.PN~CD~Questions~1701-1800 - 17 1.

Review the components of a low-sodium diet if you had difficulty with this question.PN~CD~Questions~1701-1800 - 18 Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills References: Elkin. To provide essential fatty acids and additional calories Answer: 4 Rationale: Clients receiving their total nutrition parenterally for a prolonged period of time are at risk for developing essential fatty acid deficiency. Nutrition essentials and diet therapy (9th ed. To increase the amount of fluid intake 2. M. Options 1. 1732.. Lifelong medication is necessary in the treatment of hypertension. Test-Taking Strategy: Use the process of elimination.B. 2. 243. N.” 3. & Potter. Nursing interventions and clinical skills (3rd ed).). which cannot be met by TPN administration alone. will direct you to option 4. Canned foods use salt as a preservative and should not be encouraged as part of a low-sodium diet.. “The reason I need lower salt intake is to reduce fluid retention. “This diet is not a replacement for my antihypertensive medications. St. Louis: Mosby. To add bulk to the client’s system 3. (2003). Focusing on the issue. 318. St.. which leads to hypertension secondary to increased fluid volume. pp. Sodium retains fluid. “This diet will help to lower my blood pressure. P. Perry. A physician orders an intravenous fat emulsion solution for a client who will be receiving total parenteral nutrition (TPN). P. Louis: Mosby. p. “Canned foods are inexpensive and are good to use on a low-sodium diet. 156. (2004). a low-sodium diet. 241. A.).” 2.” 4. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh. A. Clinical nursing skills & techniques (5th ed. The nurse explains to the client that the fat emulsion solution is administered: 1. 750. p. Saunders. Fat emulsions are given to meet client nonprotein caloric needs and provide essential fatty acids. (2004). These words indicate a false-response question and that you need to select the incorrect client statement. To prevent fluid volume deficit 4. A nurse has completed diet teaching for a client on a low-sodium diet for hypertension. 1733. Note the relation between “fat . and 3 are incorrect. Test-Taking Strategy: Use the process of elimination noting the key words further teaching is necessary. The nurse determines that further teaching is necessary when the client makes which of these statements? 1. Perry. & Potter.” Answer: 4 Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Philadelphia: W.

Louis: Mosby. Normal saline 3.). A sodium level of 132 mEq/L is low. and injection sites are rotated systematically. & Salerno. Knowing this.. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: McKenry. indicating hyponatremia. E. Louis: Mosby. and the medication is injected deep into fatty abdominal tissue. E. Aspirates before injection 4. Review the subcutaneous procedure for injections if you had difficulty with this question. In clients with hyponatremia. If you had difficulty with this question. (2003).). (2001). The nurse ensures that which of the following solutions is placed in the client’s room to be used for the irrigation when the client’s serum electrolyte results indicate a potassium level of 4. A nurse teaches a client how to administer enoxaparin (Lovenox) subcutaneously. Tap water 4. Bunches the skin before injection 2.PN~CD~Questions~1701-1800 - 19 emulsion” in the question and “fatty acids” in the correct option. The needle is withdrawn gently to minimize bleeding.5 mEq/L and a sodium level of 132 mEq/L? 1. Massages after injection Answer: 1 Rationale: With subcutaneous injection of enoxaparin. review the purpose of administering fat emulsion during TPN therapy. select the option that is a standard subcutaneous injection technique. A nurse is caring for a client with a nasogastric tube who has orders to have the tube irrigated once every 8 hours. Test-Taking Strategy: Use the process of elimination. L. p. 91.. 1734. Uses a 1-inch needle 3. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen. normal . 532. 1735. A “bunching” technique or Z-track technique is used. The smallest gauge needle available (25 to 27 gauge) is used to prevent injection site hematoma. Aspiration before injecting is not done.5 mEq/L is within normal range. and the injection site is not massaged. Mosby’s pharmacology in nursing (21st ed. p. 5% dextrose solution Answer: 2 Rationale: A potassium level of 4. The nurse determines that the client understands the correct procedure if the client does which of the following on a return demonstration? 1. Recall that enoxaparin is a subcutaneously administered anticoagulant medication. B. the administration technique is the same as for heparin. St. & Kockrow. Sterile water 2. St. Foundations of nursing (4th ed.

Test-Taking Strategy: Note the key words needs further information. Fish is high in phosphorus.B. It is not ordinary clinical practice to irrigate with 5% dextrose solution. Remember that options that are similar are not likely to be correct. Spinach 4. Review the tonicity of fluids and the normal potassium and sodium serum levels if you had difficulty with this question. & Workman. Saunders. Fish Answer: 1 Rationale: The client’s laboratory value reflects hypernatremia since the normal serum sodium level is 135 to 145 mEq/L.B. (2006). A client has a serum sodium level of 151 mEq/L. 345. With this in mind. Eliminate options 2 and 3 first because they are fruits and vegetables and are lower in sodium. which contain physiological saline and highly processed meats and other foods that often have sodium added as a preservative. D. These words indicate a false-response question and that you need to select the incorrect food item. Spinach and rhubarb are good food sources of calcium. American cheese 2. and the nurse conducts dietary teaching with the client about the types of foods to avoid. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Ignatavicius. pp. Select from the remaining options by knowing that the client’s condition (hyponatremia) requires use of an isotonic irrigating solution. Test-Taking Strategy: Use the process of elimination. Rhubarb 3. A nurse suspects that a co-worker is substance impaired and is self-administering narcotic medications rather than administering them to clients as prescribed. 1737. eliminate options 1 and 3 because they involve water. Review the food items high in sodium content if you had difficulty with this question. the nurse would instruct the client to avoid foods high in sodium. N. 156. Note that the client’s laboratory value reflects hypernatremia. Nutrition essentials and diet therapy (9th ed. Saunders. Select from the remaining options by recalling that cheese is a dairy product and is higher in sodium. p. Medical-surgical nursing: Critical thinking for collaborative care (5th ed.).). 1736. (2003). Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh. Philadelphia: W. M. Which of . The nurse determines that the client needs further information if the client later states that which of the following is a good food choice? 1. Philadelphia: W.. These would include foods from animal sources.PN~CD~Questions~1701-1800 - 20 (isotonic) saline should be used rather that sterile water (hypotonic) for gastrointestinal or urinary tract irrigations. 241. Based on this finding.

Report the information to the police Answer: 2 Rationale: An impaired nurse is one who is unable to function effectively because of some type of substance abuse. 3. and 4 are incorrect. This suspicion needs to be reported to the nursing supervisor who will then report to the Board of Nursing.6 mL Available 25 mg Test-Taking Strategy: Follow the formula for the calculation of the correct dose. & Claborn. Zerwekh.A. S. The medication label states meperidine hydrochloride (Demerol) 25 mg/mL. Saunders. p. Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader. 80-81. & Hogan. Formula: Desired 15 mg _______ × mL = mL per dose ______ × 1 mL = 0.. If you had difficulty with this question. Report the information to a supervisor 3.. (2004). Clinical calculations: With applications to general and specialty areas (4th ed. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee. Confront the co-worker about the suspicion 2. Philadelphia: W.B. Call the impaired nurse organization and report the co-worker 4. Test-Taking Strategy: Follow the channel of organizational structure to report situations such as this one. Philadelphia: W. A physician prescribes meperidine hydrochloride (Demerol) 15 mg intramuscularly for a client in pain. By reporting the information. (2003). . 25..B. Confronting the nurse may cause a conflict. review medication calculation problems. the nurse alerts the institution to the potential problem and sets the stage for further investigation and appropriate action. Saunders. Fundamentals of nursing: Caring and clinical judgment (2nd ed. Saunders. Review this content if you had difficulty with this question. Philadelphia: W. Recheck your work using a calculator and make sure that the answer makes sense.B. Nursing today: Transitions and trends (4th ed. Nurse practice acts require reporting the suspicion of impaired nurses. Level of Cognitive Ability: Application Client Needs: Safe. p. pp. How many milliliters will the nurse administer to the client? Answer: 0.). J. (2004).).PN~CD~Questions~1701-1800 - 21 the following actions will the nurse take? 1. & Marshall. The supervisor will report the substance abuse situation as necessary. It is not necessary to perform a conversion with this problem.). The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. H. J. Options 1. J. M. 437. <AQ>1738.6 Rationale: Use the formula for calculating medication doses.

S. If you had difficulty with this question.B. J. & Marshall..B. Test-Taking Strategy: In this medication calculation problem. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee.). How many capsule(s) will the nurse prepare to administer the dose? Answer: 2 Rationale: Convert 0. Test-Taking Strategy: In this medication calculation problem. Once you have done the conversion and reread the medication calculation problem. How many tablets will the nurse administer to the client? Answer: 1 Rationale: Convert 0. <AQ>1741. Once you have done the conversion and reread the medication calculation problem. The label on the medication bottle states atenolol (Tenormin) 50-mg tablets.2 g orally twice daily. you will know that one tablet is the correct answer. Saunders.25 mg/tablet. you will know that two capsules is the correct answer. In the metric system. to convert larger to smaller multiply by 1000 or move the decimal three places to the right. Therefore 0.05 g = 50 mg.2 g to mg. to convert larger to smaller multiply by 1000 or move the decimal three places to the right. Philadelphia: W. Recheck your work with a calculator and make sure that the answer makes sense. Therefore 0. <AQ>1740. The medication label states 100-mg capsules. Saunders. it is necessary to first convert grams to milligrams. A physician prescribes atenolol (Tenormin) 0.PN~CD~Questions~1701-1800 - 22 <AQ>1739. (2004). 80-81. Clinical calculations: With applications to general and specialty areas (4th ed. Follow the formula for the calculation of the correct dose. Follow the formula for the calculation of the correct dose. review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee. Philadelphia: W. J.05 g orally daily. pp. 80-81. In the metric system. pp. Formula: Desired 0. If you had difficulty with this question. Clinical calculations: With applications to general and specialty areas (4th ed.5 mg .05 g to mg. The nurse will administer one tablet.2 g = 200 mg. & Marshall.. A physician prescribes digoxin (Lanoxin) 0. review medication calculation problems.5 mg PO daily for a client with congestive heart failure. (2004).). The medication label states 0. it is necessary to first convert grams to milligrams. Recheck your work with a calculator and make sure that the answer makes sense. How many tablet(s) will the nurse administer to the client? Answer: 2 Rationale: Follow the formula for the calculation of the correct dose. The nurse will administer two capsules. S. A physician prescribes phenytoin (Dilantin) 0.

S. <AQ>1742.PN~CD~Questions~1701-1800 - 23 _______ × 1 tablet = tablet per dose ______ × 1 tablet = 2 tablets Available 0. Saunders. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee. tuberculosis is suspected.). Recheck your work using a calculator and make sure that the answer makes sense. Clinical calculations: With applications to general and specialty areas (4th ed. 80-81. A pregnant woman reports to the health care clinic complaining of loss of appetite.5 Rationale: Convert 150 mcg to mg. It is not necessary to perform a conversion with this problem. review medication calculation problems. Label each figure including the answer.). If you had difficulty with this question. Philadelphia: W. Medication will not be started until after delivery of the fetus 2. & Marshall. pp. J..B. Formula: Desired 0.15 mg.. Label each figure including the answer. In the metric system.1 mg Test-Taking Strategy: In this medication calculation problem. A physician prescribes levothyroxine (Synthroid) 150 mcg orally daily for a client with hypothyroidism. Saunders. Recheck your work with a calculator and make sure that the answer makes sense. pp. 80-81. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Kee. Therefore 150 mcg = 0.1 mg/tablet. use the formula for determining the correct dose. J. 1743. S. (2004). If you had difficulty with this question. Next. Clinical calculations: With applications to general and specialty areas (4th ed. Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months 3. it is necessary to first convert micrograms to milligrams. follow the formula for the calculation of the correct dose. weight loss. The nurse reinforces instructions to the client regarding therapeutic management of the tuberculosis and tells the client that: 1. Following an assessment. and fatigue. Philadelphia: W. The home care nurse will instruct the client to take how many tablet(s)? Answer: 1. The medication label states 0. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum.25 mg Test-Taking Strategy: Follow the formula for the calculation of the correct dose.B. The need for therapeutic abortion is required Answer: 2 Rationale: More than one medication may be used to prevent growth of resistant . to convert smaller to larger divide by 1000 or move the decimal three places to the left. & Marshall. Next.5 tablet Available 0.15 mg _______ × 1 tablet = tablet per dose ______ × 1 tablet = 1. The newborn infant must receive medication therapy immediately following birth. (2004). 4. review medication calculation problems.

review treatment measures for the mother with tuberculosis. E. Maternity & women’s health care (8th ed. & Perry..E. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk. & Gorrie. (2002). 1069-1070. If the skin test result converts to positive. Test-Taking Strategy: Knowledge regarding the therapeutic management for the mother with tuberculosis and for the newborn infant is required to answer this question.B. Murray. 430.). and 4 are goals of care. 730. Although options 2. Louis: Mosby. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to: 1.E. Prevent further stress on the maternal immune system 2.. and 4 because of the absolute words “not. p. Minimize the possibility of preterm labor 4. Collectively. T. and isoniazid may be stopped if the skin test result remains negative. Treatment must continue for a prolonged period of time. Skin testing should be repeated at 3 months on the infant. pp. Foundations of maternal-newborn nursing (3rd ed. S. Minimize the risk of premature rupture of the membranes Answer: 1 Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client and not getting appropriate rest can compromise the maternal immune system. Reduce the risks of anemia during pregnancy 3. McKinney. Philadelphia: W. St..” “must. (2004). D. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk. Maternity & women’s health care (8th ed.). Ethambutol is also added initially if drug resistance is suspected. The preferred treatment for pregnant woman is daily isoniazid plus rifampin for a total of 9 months. St. Louis: Mosby. Although all of the options are important. Saunders. Test-Taking Strategy: Use the process of elimination and focus on the diagnosis of the client. The infant will be tested at birth and may be started on preventive isoniazid therapy. pp.). Note the key words primarily in the question and immune in the correct option.. 3. the option that specifically relates to the client with HIV is option 1. 3. .” and “required.” respectively. such factors may place both the mother and fetus at additional risk during the pregnancy. If you had difficulty with this question. S. 124. 1744. S. A nurse is reinforcing information about health care to a pregnant client that is human immunodeficiency virus (HIV) positive.PN~CD~Questions~1701-1800 - 24 organisms in the pregnant woman with tuberculosis. Eliminate options 1. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. a full course of isoniazid would be given. (2004). & Perry. option 1 represents the primary management issue for the HIV-infected client. D. Review care measures for the pregnant client with HIV if you had difficulty with this question.

” 4. and iron stores. E.). Philadelphia: W.).). D. Neonates of severely anemic mothers have been reported to experience reduced red cell volume. Complications are rare.) Answer: 21 Rationale: The first step is to determine how many hours the IV will last. but let’s review your plan of care to ensure that you are providing the best nutrition and growth potential. (2002). S. The nurse sets the flow rate at how many gtt per minute? (Round answer to the nearest whole number. review therapeutic communication techniques and the effects of maternal anemia on the fetus. Saunders. hemoglobin. “Your baby will need to spend a few days in the neonatal intensive care unit following delivery. (2004). Eliminate options 1 and 3 because these options provide a false reassurance to the client.” 3. Foundations of maternal-newborn nursing (3rd ed. Maternity & women’s health care (8th ed. If you had difficulty with this question... “You will not have any problems if you follow all the advice the physician has given you. St. This requires simple division of the total volume of milliliters to be infused (1000 mL) by the total milliliters per hour (125 mL).E. Which nursing response would best support the client? 1. McKinney. In general it is believed that the fetus will receive adequate maternal stores of iron. use the formula to calculate the flow rate. Saunders. Murray. p.. McKinney. even if a deficiency is present. (2002). Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum References: Lowdermilk. 717-718. “The effects of anemia on your baby are difficult to predict. & Gorrie. The gtt factor is 10 gtt/mL. which is 480 minutes (8 hours × 60 minutes). S. “Don’t worry about your baby..PN~CD~Questions~1701-1800 Murray. <AQ>1746. Option 2 will cause further concern in the client. Foundations of maternal-newborn nursing (3rd ed.B. T. pp..B. 25 1745.” Answer: 4 Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. pp. Options 1 and 3 provide a false reassurance to the client. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client’s plan of care to clarify information and reassure the mother. Louis: Mosby. 728. & Gorrie. This calculates to 8 hours and is then converted to minutes. T. & Perry. Next. Eliminate option 2 next because this response will cause further concern in the client.” 2. A pregnant client who is anemic tells the nurse that she is concerned about her baby’s condition following delivery. A client is to receive 1000 mL of 5% dextrose in water over a time period of 125 mL/hr. 918-919. E. Philadelphia: W. S. Formula: Total volume in mL × gtt factor ____________________________ = Flow rate in gtt per minute .

St.. The nurse would assess for pallor and coolness of the affected extremity. Test-Taking Strategy: Focus on the issue. Checking pin sites for drainage provides information about infection.). 1747. J. 150. E. A physician prescribes 1000 mL of normal saline to be infused over a period of 12 hours.PN~CD~Questions~1701-1800 Time in minutes 26 1000 mL × 10 gtt 10000 _________________ = _________ = 20. it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury.) . Check the blood pressure 2. The client should not be encouraged to perform active ROM exercises with an extremity that is fractured and in traction. Saunders. A client with a fractured femur is placed in skeletal traction.. Louis: Mosby. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Christensen.8 or 21 gtt/min 480 minutes 480 Test-Taking Strategy: Use the formula for IV infusion rates when calculating these IV problems. Monitor the client’s ability to perform active range of motion (ROM) exercises to the affected extremity 4. The gtt factor is 15 gtt/mL. Remember to round the answer to the nearest whole number. p. (2004). p. Be careful with the multiplication and division. S. Adult health nursing (4th ed. Note the relation between the issue and option 2. B. Philadelphia: W. or complaints of increasing pain. The nurse should do which of the following to monitor for nerve injury? 1. Although the blood pressure measurement provides an overall indication of circulatory status.). & Kockrow. Remember that you need to convert hours to minutes. monitoring for nerve injury. Check the pin sites for drainage Answer: 2 Rationale: Bone fragments and tissue edema associated with a fracture can cause nerve damage. <AQ>1748. Review the formula for calculating IV infusion rates if you had difficulty with this question. & Marshall. Clinical calculations: With applications to general and specialty areas (4th ed. (2003). Check the neurovascular status of the affected extremity 3.B. 212. Review the signs and symptoms of nerve injury following a fracture if you had difficulty with this question. paresthesias. The nurse sets the flow rate at how many gtt per minute? (Round answer to the nearest whole number. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee.

3. Asking the client if he or she can hear the nurse or leaving the room and returning later to continue with the discussion may be viewed as a rude gesture by the client. If the client turns away from the nurse during a conversation. H.. the nurse begins to discuss the plan of care for the day. Formula: Total volume in mL × gtt factor ____________________________ = Flow rate in gtt per minute Time in minutes 27 1000 mL X 15 gtt 15000 _________________ = _________ = 20.. M. the best action is to continue with the conversation. review the communication practices of this cultural group. p. If you had difficulty with this question. A nurse is assigned to care for a client that is Asian. Clinical calculations: With applications to general and specialty areas (4th ed.). The nurse enters the room and following a greeting and introduction to the client. S. & Marshall. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Harkreader.). Remember to convert hours to minutes. the client turns away from the nurse. . Saunders. Continue with the discussion 2. During the discussion. Philadelphia: W. Ask the client if he or she can hear the nurse 3. 1749. (2004). Philadelphia: W. Be careful with the multiplication and division and use a calculator to check your answer. Fundamentals of nursing: Caring and clinical judgment (2nd ed. 53. Return later to continue with the discussion 4. (2004).8 or 21 gtt/min 720 minutes 720 Test-Taking Strategy: Use the formula for IV infusion rates when calculating these IV problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee. direct eye contact is often viewed as being rude. Saunders.A. p. Convert 12 hours to minutes (12 hours × 60 minutes = 720 minutes). Leave the room and ask for another nurse to be assigned to the client Answer: 1 Rationale: In Asian cultures. Eliminate options 2.PN~CD~Questions~1701-1800 Answer: 21 Rationale: Use the formula for calculating IV infusion rates. 212. and 4 because these are nontherapeutic actions. & Hogan.B.B. Test-Taking Strategy: Knowledge of the characteristics of this cultural group and therapeutic communication techniques will assist in answering this question. Review the formula for calculating IV infusion rates if you had difficulty with this question. J. The nurse should take which action? 1.

).B. ulcerative colitis. The resin either passes through the intestine or is retained in the colon. . If you had difficulty with this question.PN~CD~Questions~1701-1800 - 28 1750. N. review the risk factors associated with hyperkalemia. review the action of this medication. which indicates potassium excretion. If you had difficulty with this question. Ulcerative colitis 2. The client with Cushing’s syndrome. remember that Cushing’s syndrome presents a risk for hypokalemia. Diarrhea 3. Philadelphia: W. This will assist in directing you to option 2. The nurse would determine that this is an expected finding if the client had which of the following health problems? 1. 1751. It releases sodium ions in exchange for primarily potassium ions. 783. With this in mind. whereas Addison’s disease presents a risk for hyperkalemia.5 mEq/L. and the registered nurse asks the nursing student how the medication works.. The student correctly responds that the medication works in the gastrointestinal tract by releasing: 1. A. Introduction to medical-surgical nursing (3rd ed. A nurse reviews an assigned client’s laboratory report and notes a serum potassium level of 5. (2003). This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Also. Potassium ions in exchange for primarily sodium ions Answer: 2 Rationale: Sodium polystyrene sulfonate (Kayexalate) is a cation exchange resin used in the treatment of hyperkalemia. p. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic ketoacidosis). Kayexalate. Sodium ions in exchange for primarily potassium ions 3. Test-Taking Strategy: Use the process of elimination.1 mEq/L indicates hyperkalemia. & Maebius. Bicarbonate in exchange for primarily sodium ions 4. Saunders. From the remaining options recalling that cell destruction causes potassium shifts will direct you to the correct option. Cushing’s syndrome Answer: 3 Rationale: A serum potassium level greater than 5. A nursing student prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client. or the client with diarrhea is at risk for hypokalemia. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton. Sodium ions in exchange for primarily bicarbonate ions 2. Remember that options that are similar are not likely to be correct. eliminate options 1 and 2 first because they both reflect gastrointestinal losses. Test-Taking Strategy: Focus on the name of the medication. Severe burn injury 4.

restraints need to be released at least every 2 hours to permit muscle exercise and promote circulation. 512. The nurse determines that the fetal presenting part is: 1. Saunders. 1752. Philadelphia: W. Level of Cognitive Ability: Application Client Needs: Safe. R.A. & Kizior. it is best to select option 1. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question.. (2004). 1 inch below the coccyx 4. A nurse is providing instructions to the nursing assistant who will be caring for a client with hand restraints. Test-Taking Strategy: Focus on the issue. Every 2 hours 3. Saunders. p. Fundamentals of nursing: Caring and clinical judgment (2nd ed. 1753. Note that options 1. One fingerbreadth below the symphysis pubis 3. B. Additionally. A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. and skin integrity every 30 minutes. Since circulatory status is a primary concern with the use of restraints. 1 cm above the ischial spines Answer: 4 Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. Saunders nursing drug handbook 2005. checking the client’s skin and circulation under the restraints. p. The nurse instructs the nursing assistant to check the client’s skin and circulation under the restraints: 1. 1 inch below the iliac crest 2. Every 30 minutes 2. Every 4 hours Answer: 1 Rationale: The nurse should instruct the nursing assistant to assess restraints.B. Review station if you had difficulty with this question. 2. M.” which would be represented by a positive measurement in determining station. B. (2005). and is noted as a negative number above the line and a positive number below the line. Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Harkreader. Philadelphia: W. and 3 are similar in the use of “below. . Agency guidelines regarding the use of restraints should always be followed. is measured in centimeters..).PN~CD~Questions~1701-1800 - 29 Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson. Every 3 hours 4. Test-Taking Strategy: Knowledge that station is measured in centimeters and uses the ischial spines as a reference point will assist in answering this question. H. & Hogan. circulatory status. 980.

Eliminate options 1 and 2 because these actions may be interpreted as client abandonment. Discuss her anxieties and concerns about floating with the nursing supervisor. A 22-year-old client who was struck by a car while jogging is brought to the emergency room by the ambulance team. and a ruptured spleen is suspected. 1755... Louis: Mosby. Ask another pediatric nurse to float to the emergency room Answer: 3 Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Next. Level of Cognitive Ability: Application Client Needs: Safe. which of the following should the nurse implement initially? 1. Test-Taking Strategy: Note the key word appropriate. In anticipation that the client’s eyes will be donated. 418-419. Tell the nursing supervisor that she is feeling sick and needs to go home 2. Maternity & women’s health care (8th ed. Which of the following is the appropriate nursing action? 1. 470. Review nursing responsibilities related to “floating” if you had difficulty with this question. but are unsuccessful. a nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. S. Louis: Mosby. it is not the appropriate action. (2004). nurses discuss any anxieties and concerns about floating with the nursing supervisor. D. When encountered with this situation. St. The nurse has never worked in the emergency room and is anxious about floating to this area. Legally.). P. Although option 4 may be an alternative option at some point.E. A pediatric nurse arrives at work and is told to report (float) to the emergency room for the day because the emergency room is expecting numerous victims to arrive following a train accident. pp. 472. A. 4. Refuse to float to the emergency room 3. & Perry. Emergency measures are instituted. Options 1 and 2 may be interpreted as client abandonment. St. (2005). Call the National Eye Bank to confirm that the client is a donor 2. Position the deceased client supine and place dry sterile dressings over the eyes 3. Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Potter. pp. The client is unconscious. & Perry. Close the deceased client’s eyes and place a small ice pack on the eyes . 1754. eliminate option 4 because it is not within the realm of the nurse’s responsibilities to ask another nurse to float. The client’s fiancée is with the client and tells the nurse that the client is an organ donor.). Fundamentals of nursing (6th ed.PN~CD~Questions~1701-1800 - 30 Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Lowdermilk.

. D. A nurse is collecting data from a pregnant client and is preparing to take the client’s blood pressure. & Gorrie.). Noting the words “close the deceased client’s eyes” in option 3 will direct you to this option. Antibiotic eyedrops may also be prescribed.). Louis: Mosby. 3. On the right side 4.. McKinney. (2006). Saunders. Test-Taking Strategy: Note the key word initially. St. and these positions may cause physiological stress that will affect the blood pressure. If you are unfamiliar with the procedure of performing a blood pressure on a pregnant client. p. the client’s eyes are closed. The nurse positions the client: 1. These actions will assist in preventing infection and edema. Philadelphia: W. Maternity & women’s health care (8th ed.). (2002).PN~CD~Questions~1701-1800 - 31 4. Calling the National Eye Bank to confirm that the client is a donor will delay necessary and immediate intervention. 840.B. p. Saunders. Option 2 is incorrect. p. Level of Cognitive Ability: Application Client Needs: Safe. Test-Taking Strategy: Use the process of elimination noting that options 1. and gauze pads with a small ice pack are placed on the client’s eyes. The nurse measures the fundal height in centimeters and expects the findings . the method for obtaining blood pressure should be standardized as much as possible. The head of the bed should also be elevated. & Perry. 1092. T. S. Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Ignatavicius. Foundations of maternal-newborn nursing (3rd ed. This indicates that the nurse needs to take an action that will preserve the integrity of the deceased client’s eyes. S.E. & Workman. 143. 1756. D. E. Blood pressure should be obtained with the client in the sitting position with the arm supported in a horizontal position at heart level.. Lying down 2. 3. (2004). Ask the fiancée to obtain the client’s will from the lawyer Answer: 3 Rationale: When a corneal donation is anticipated. and option 4 is unnecessary. Review this procedure if you had difficulty with the question.B. In a sitting position 3. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk. The cornea is usually transplanted within 24 to 48 hours. Options 1. 1757. Murray. On the left side Answer: 2 Rationale: Because position affects blood pressure in the pregnant woman. Philadelphia: W. and 4 are incorrect. Medical-surgical nursing: Critical thinking for collaborative care (5th ed. review this procedure. M.. and 4 are similar. A nurse is assisting in performing an assessment on a client that is 32 weeks’ gestation. Within 2 to 4 hours the eyes are enucleated.

If an unexpected increase in uterine size is present. A softening of the cervix 2. and the pregnancy is further advanced than previously thought. Remember that in the early weeks of pregnancy. Recalling that in this client the fundal height measured in centimeters will be roughly plus or minus 2 cm of the gestational age of the fetus in weeks will direct you to option 3. The presence of human chorionic gonadotropin (hCG) in the urine 4. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus 3.). 416. & Perry. Goodell’s sign does not indicate the presence of fetal movement. it may be that the estimated date of delivery is incorrect. additional assessment is necessary to investigate the cause for the unexpected uterine size.PN~CD~Questions~1701-1800 - 32 to be which of the following? 1. If you had difficulty with this question. If the fundal height exceeds weeks’ gestation. Human chorionic gonadotropin is noted in maternal urine in a urine pregnancy test.E. review this content. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is due to blood circulation through the placenta. 40 cm Answer: 3 Rationale: From 22 weeks until term. and the nurse determines that this sign is indicative of: 1. 1758. If the estimated date of delivery is correct. If you are unfamiliar with this assessment technique. the cervix becomes softer as a result of pelvic vasoconstriction.. Maternity & women’s health care (8th ed. review the changes in the cervix that occur during pregnancy. p. S. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk. Test-Taking Strategy: Knowledge regarding the expected findings in fundal height in a pregnant client from 22 weeks’ gestation until term is required to answer this question. Louis: Mosby. which causes Goodell’s sign. A nurse is reviewing the record of a client who has just been told that a pregnancy test result is positive. 28 cm 3. D. which causes Goodell’s sign. St. 32 cm 4. Cervical softening will be noted during pelvic examination by the examiner. it may be possible that more than one fetus is present. the cervix becomes softer as a result of pelvic vasoconstriction. 22 cm 2. the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. Test-Taking Strategy: Knowledge regarding physiological findings in Goodell’s sign is required to answer this question. The presence of fetal movement Answer: 1 Rationale: In the early weeks of pregnancy. The physician has documented the presence of Goodell’s sign. Level of Cognitive Ability: Comprehension . (2004).

although many expectant mothers do not notice them until the . Braxton Hicks contractions are irregular. “It is the thinning of the lower uterine segment. & Potter. D. painless contractions that occur throughout pregnancy. The other three options are likely to be accompanied by warmth at the site.. The nurse checks the IV site and notes that it is also cool and pale and that the IV has stopped running. A nursing instructor asks a nursing student to describe the process of quickening.). This sound is due to the blood circulation to the placenta and corresponds to the maternal pulse. “It is the soft blowing sound that can be heard when the uterus is auscultated. Clinical nursing skills & techniques (5th ed. 576. When the pressure in the tissue exceeds the pressure in the tubing. Louis: Mosby. If this question was difficult. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus. St. it is necessary to be familiar with the signs and symptoms that accompany complications of IV therapy. Test-Taking Strategy: To answer this question accurately. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Perry. Which statement by the student indicates an understanding of this term? 1. (2004). the flow of the IV solution will stop. The pallor. St. review the signs of infiltration. Thrombosis 4.” 3.” Answer: 3 Rationale: Quickening is fetal movement and is not perceived until the second trimester. and swelling are the result of IV fluid being deposited in the subcutaneous tissue. The corrective action is to remove the catheter and start a new IV line. (2004). A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse that the IV site is swollen. p. Infiltration 2. Maternity & women’s health care (8th ed..). 1760. Focusing on the findings in the question will direct you to option 1.PN~CD~Questions~1701-1800 - 33 Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk. not coolness. coolness.E. S. 352.” 4. painless contractions that occur throughout pregnancy.” 2. Louis: Mosby. and this in known as uterine souffle. p. “It is irregular. the expectant mother first notices subtle fetal movements that gradually increase in intensity. A. Between 16 and 20 weeks’ gestation. P. Infection Answer: 1 Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. & Perry. The nurse documents that which of the following has probably occurred? 1. Phlebitis 3. 1759. “It is the fetal movement that is felt by the mother.

A nurse-midwife is performing an assessment on a pregnant client and is assessing the client for the presence of ballottement. A thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegar’s sign. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk. The examiner .. 418. Assess the cervix for thinning 4. & Perry.PN~CD~Questions~1701-1800 - 34 third trimester. 10 to 12 weeks 3. 398. (2004). review this procedure. St. Test-Taking Strategy: Knowledge regarding the term “quickening” is required to answer this question. 14 to 16 weeks 4. Auscultate for fetal heart sounds 2. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Lowdermilk. The nurse who is assisting understands that the nurse-midwife will implement which of the following to test for the presence of ballottement? 1. Recalling that quickening is fetal movement will direct you to option 3. the fetus floats upward in the amniotic fluid. D. 1762. review this content. a sudden tap on the cervix during a vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position. D. Noting the key word fetoscope in the question will assist in directing you to option 4. p. pp. When the cervix is tapped. Palpate the abdomen for fetal movement 3. 1761.). 2. St.).E. 8 to 10 weeks 2. S. Louis: Mosby. The nurse prepares to use a fetoscope knowing that fetal heart sounds can be heard with a fetoscope by which week of gestation? 1. If you are unfamiliar with the assessment of and auscultation of fetal heart sounds.E. Options 1. If you are unfamiliar with the signs associated with pregnancy. and 3 are incorrect because the fetal heart sounds cannot be heard with a fetoscope at these gestational times. Maternity & women’s health care (8th ed. Initiate a sudden tap on the cervix Answer: 4 Rationale: Near midpregnancy. 18 to 20 weeks Answer: 4 Rationale: Fetal heart sounds can be heard with a fetoscope by 18 to 20 weeks’ gestation. (2004). Louis: Mosby. A nurse is collecting data on a pregnant client and is preparing to auscultate the fetal heart sounds. 354. Test-Taking Strategy: Knowledge regarding auscultation of fetal heart sounds is required to answer this question. S.. Maternity & women’s health care (8th ed. & Perry.

PN~CD~Questions~1701-1800 - 35 feels a rebound when the fetus falls down.). Apply ice packs to the site 4. 136-137. the nurse notifies the RN who will notify the . (2004). 60 minutes Answer: 2 Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion.). 623-624. S. pp. Remember that ballottement relates to a rebound of the fetus.B. Test-Taking Strategy: Specific knowledge related to blood transfusion procedures is needed to answer this question accurately. St. A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBC) on a client.. & Perry. and 3 are incorrect. Review the procedure for administering blood transfusions if you had difficulty with this question. The time frames in options 3 and 4 are unnecessary. Options 1. Remember that the client needs to be directly monitored for the first 15 minutes of the transfusion. Slow the rate of the IV infusion 2.. S. Test-Taking Strategy: Knowledge regarding assessment of ballottement in the pregnant client is required to answer this question. & Gorrie. 2. T. (2004). P. (2002). McKinney. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Perry. A client is complaining of pain at the site of the intravenous (IV) infusion device. Clinical nursing skills & techniques (5th ed. Louis: Mosby. review this content. This enables the nurse to quickly detect a reaction and intervene quickly. A. Maternity & women’s health care (8th ed. Foundations of maternal-newborn nursing (3rd ed. Philadelphia: W. The licensed practical nurse who is assisting in caring for the client plans to remain with the client for how many minutes following the start of the infusion? 1. E.. pp. Which of the following actions should the nurse take? 1. Louis: Mosby. & Potter. 1764.). 1763.E. Notify the registered nurse (RN) 3. 583. 30 minutes 4.. St. D. Option 1 is not ample time to remain with the client. The nurse checks the IV site and determines that the client has phlebitis. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk. p. 15 minutes 3. If you are unfamiliar with this assessment technique. Saunders. Plan to assist with starting a new line in a proximal portion of the same vein Answer: 2 Rationale: Since phlebitis has occurred. which is the most frequent period during which a transfusion reaction may occur. 5 minutes 2. Murray.

& Hogan. Which of the following most appropriately describes the ChineseAmerican’s view of illness? 1. After returning the client to bed and conducting an initial assessment. M. A. In the African-American culture. Native Americans believe that illness is caused by supernatural forces.PN~CD~Questions~1701-1800 - 36 physician about the IV complication. & Potter. Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Test-Taking Strategy: Focus on the issue.B. pp. In the high-Fowler’s position 3. Louis: Mosby. St. 576-577. (2004). Clinical nursing skills & techniques (5th ed. 54. The nurse should plan to remove the IV and apply warm moist compresses to the area to speed resolution of the inflammation. Illness is a punishment for sins 3. H. Review nursing interventions related to phlebitis if you had difficulty with this question. Philadelphia: W. P. The nurse should plan to assist in restarting the IV in a different vein from the one with the phlebitis. p. phlebitis at an IV site. With the head of bed elevated at least 60 degrees . Illness is a disharmonious state that may be caused by demons and spirits 4. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry. which they believe is caused by prolonged sitting or lying or overexertion.A. Saunders. review these various beliefs. illness is viewed as a disharmonious state that may be caused by demons and spirits. Hispanic Americans believe that illness occurs as a result of punishment for sins. 1765. 1766. (2004). If you had difficulty with the question. With the foot of bed elevated as much as tolerated by client 2. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Harkreader. Test-Taking Strategy: Use the process of elimination and focus on the health beliefs of the Chinese-American culture. the nurse assisting in caring for the client places a sign above the bed stating that the client should remain on bed rest: 1. A nurse caring for a Chinese-American client plans care considering the client’s view of illness... The left femoral vessel was used as the access site. Thinking about the physiological effect of each of the actions identified in the options will assist in directing you to option 2. Illness is caused by supernatural forces 2.). A client has just returned from the cardiac catheterization laboratory. Illness is due to an imbalance between yin and yang Answer: 4 Rationale: Chinese Americans believe that illness is due to an imbalance between yin and yang.

the nurse interprets that the client probably needs this type of solution because it: 1. & Kockrow. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Lowdermilk. A pregnant client asks a nurse in the clinic when she will be able to start feeling the fetus move. 292. 8 to 10 weeks’ gestation 3. Test-Taking Strategy: Use the process of elimination. Louis: Mosby. The nurse responds by telling the mother that fetal movements will be noted between: 1. E. If you had difficulty with this question. 1767.. S. Use the process of elimination. 354.9% sodium chloride to infuse at 100 mL/hr.). is not perceived until the second trimester. review this assessment finding. St. review postcardiac catheterization care. Test-Taking Strategy: Knowledge regarding quickening and the detection of fetal movement by the mother are required to answer this question. (2004). 1768. St. B. the expectant mother first notices subtle fetal movements that gradually increase in intensity. 16 to 20 weeks’ gestation Answer: 4 Rationale: Fetal movement. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen.E. remembering that the affected leg is kept straight will assist in eliminating option 1. Eliminate options 2 and 3 first because they are similar. (2003). Louis: Mosby. 6 to 8 weeks’ gestation 2. If the femoral artery was used. and the head is elevated no more than 30 degrees until hemostasis is adequately achieved. When determining the rationale for the change in fluid.. the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. Will increase the plasma osmolarity . and in this situation it is best to select the option that indicates the greatest length of gestational time. D. With the head of bed elevated no more than 30 degrees Answer: 4 Rationale: Following cardiac catheterization. Between 16 to 20 weeks’ gestation. 12 to 14 weeks’ gestation 4.PN~CD~Questions~1701-1800 - 37 4. The affected leg is kept straight. called quickening. p. Adult health nursing (4th ed. If you are unfamiliar with the process of quickening. The client may turn from side to side. strict bed rest is enforced for 6 to 12 hours or per agency procedure. & Perry. From the remaining options. Maternity & women’s health care (8th ed. A client with an indwelling intravenous (IV) catheter has an order for an IV solution to be changed to 1000 mL of 0. p.).

Wound drain and skin 2.. and urine output. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Potter.). St. 1769. St. 2. Recalling that insensible losses cannot be measured will direct you to option 2. A physician is discussing the fluid balance of a postoperative client. P. 1770. 48. B. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen. Foley catheter and nasogastric tube Answer: 2 Rationale: Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. Options 1.9% is isotonic and is frequently used for intravenous infusion because it does not affect the plasma osmolarity. Remember that options that are similar are not likely to be correct. Hypertension . Nasogastric tube and wound drain 4. Is hypotonic with the plasma and other body fluids Answer: 3 Rationale: Sodium chloride 0. Laënnec’s cirrhosis 4. Louis: Mosby. & Kockrow. Review sensible and insensible fluid losses if you had difficulty with this question. (2005). p. Is isotonic with the plasma and other body fluids 4. The nurse determines that third-spacing of fluids is least likely to develop in the client with: 1. Louis: Mosby. Skin and lungs 3. They occur on a daily basis without the client’s awareness. Review the various types of IV solutions if you had difficulty with this question. The physician states that the client’s insensible fluid loss is approximately 600 mL daily. & Perry. Adult health nursing (4th ed. (2003).PN~CD~Questions~1701-1800 - 38 2. Renal failure 3. p. E. Will decrease the plasma osmolarity 3. Remembering that the normal concentration of saline in the body is 0. and 4 are incorrect regarding this type of solution. Fundamentals of nursing (6th ed. eliminate options 2 and 4. The nurse interprets that the physician is referring to fluid loss that is occurring thorough the: 1. gastrointestinal tract losses. Test-Taking Strategy: Use the process of elimination and knowledge regarding the concepts related to body fluids. Sensible losses are those that are measurable and include wound drainage. Major burn 2.). A nurse is assigned to care for a group of clients on the clinical nursing unit.9% will direct you to option 3. A.. With this in mind. 1137. Test-Taking Strategy: Note the key words insensible fluid loss.

pp. conditions that cause increased respiratory rate or urine output. 218-219. A nurse is caring for a group of clients on a clinical nursing unit. or the presence of an ileostomy or colostomy. J. Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). The nurse interprets that which of the following assigned clients is most at risk for excess fluid . N. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Black. A client with congestive heart failure 2. 1772. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. 1771.PN~CD~Questions~1701-1800 - 39 Answer: 4 Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. pp. Other causes of deficient fluid volume include vomiting. & Maebius. Test-Taking Strategy: Read the question carefully noting that it asks for the client at risk for a deficit.B. (2005). major trauma. 2.. insufficient IV fluid replacement. If you had difficulty with this question. The nurse checks for signs of deficient fluid volume in which of the following clients that is most at risk for this fluid imbalance? 1. renal failure. major surgery. Clients who have the disorders presented in options 1. Read each option and think about the fluid imbalance that can occur in each. Philadelphia: W.. Philadelphia: W. Saunders. and gastrointestinal malabsorption and malnutrition. A. review these concepts and the causes of third-spacing. A client with an ileostomy 4. Risk factors include the older client and those with liver or kidney disease. sepsis. and 4 would be likely to retain fluid rather than lose it. review the causes of deficient fluid volume. Saunders.349-350. Introduction to medical-surgical nursing (3rd ed.). & Hawks. diarrhea. If you had difficulty with this question. Clients who have heart failure. burns. (2003). J. 213. malignancy. A nurse is caring for a group of clients on a clinical nursing unit. A client with acute renal failure 3. 158-159. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton. Test-Taking Strategy: Use the process of elimination recalling the concepts of thirdspacing of fluids. Noting the key words least likely will direct you to option 4. A client with major trauma Answer: 3 Rationale: The client with an ileostomy is at risk for deficient fluid volume because of increased gastrointestinal tract losses. draining fistulas.B. or major trauma are at risk for excess fluid volume. Common sites for third-spacing include the pleural and peritoneal cavities and the pericardial sac.

Saunders. These symptoms must reverse if the excess fluid volume is to be resolved. The client with an ileostomy. A nurse is caring for a client with cirrhosis who has a nursing diagnosis of excess fluid volume. The client with a draining abdominal wound 2. N. If you had difficulty with this question. dyspnea. Decreasing body weight 4. Other causes of excess fluid volume include heart failure.PN~CD~Questions~1701-1800 - 40 volume? 1.. The other options listed indicate that the client is retaining additional fluid. Recalling the effects of fluid on various physical assessment findings will direct you to option 3. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation . A. Increasing central venous pressure 2. rales.). (2003). weight gain. and 4 lose fluid. neck and hand vein distention. Increasing pulse 3. The client with a nasogastric tube to low suction 3. pp. & Maebius. and a decreased hematocrit. The client with an ileostomy Answer: 3 Rationale: The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. 2. liver disorders. and excessive ingestion of table salt.B. 782. review the causes of excess fluid volume. a draining abdominal wound. Test-Taking Strategy: Use the process of elimination. edema. 159. tachycardia. Test-Taking Strategy: Use the process of elimination and note the key word resolving. review the assessment signs noted in excess fluid volume. Read the question carefully noting that it asks for the client at risk for an excess. excessive use of hypotonic IV fluids to replace isotonic losses. tachypnea. The client with renal failure 4. an elevated blood pressure and a bounding pulse. Read each option and think about the fluid imbalance that can occur in each. altered level of consciousness. elevated central venous pressure. The nurse would determine that the diagnosis is resolving if which of the following data is obtained by the nurse? 1. Decreasing urine output Answer: 3 Rationale: A sign that excess fluid volume is resolving is loss of body weight. The clients presented in options 1. The only condition that can cause an excess is the condition noted in option 3. Introduction to medical-surgical nursing (3rd ed. Assessment findings associated with excess fluid volume include cough. 1773. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton. Philadelphia: W. If you had difficulty with this question. or a nasogastric tube is at risk for deficient fluid volume. excessive irrigation of body fluids.

PN~CD~Questions~1701-1800 - 41 Content Area: Fundamental Skills Reference: Linton. which places this client at risk for hypokalemia. R. Further follow-up would be implemented. 1774. Philadelphia: W. and 4 because they are similar in that they all identify the administration of medication to treat the elevated blood glucose. 1775. The nurse assesses this client carefully for signs of hypokalemia. and amiloride HCL are potassium-sparing diuretics. A blood glucose measurement is performed on a pregnant client. Test-Taking Strategy: Use the process of elimination recalling the classifications of the various diuretics identified in the options. Saunders nursing drug handbook 2005. N. Level of Cognitive Ability: Analysis . Review the classifications of these diuretics if you had difficulty with this question. triamterene. Spironolactone (Aldactone) 4. (2005). 159. The nurse would monitor the client for hypokalemia if the client is receiving which of the following diuretics? 1. Test-Taking Strategy: Use the steps of the nursing process remembering that data collection is the first step. Bumetanide (Bumex) Answer: 4 Rationale: Bumetanide (Bumex) is a loop diuretic. and the results indicate that the blood glucose is elevated. monitors serum potassium levels. & Maebius. (2003). B. If it is elevated. Option 3 is the only option that identifies further assessment of the client. Eliminate options 1.B. 2. 2. Amiloride HCL (Midamor) 3. Philadelphia: W. Saunders. Which of the following would the nurse anticipate to be prescribed for the mother? 1. Triamterene (Dyrenium) 2. triamterene.B. A sliding scale regular insulin dose Answer: 3 Rationale: A maternal glucose is prescribed to screen for gestational diabetes. and 4 would not be prescribed based solely on the maternal glucose levels. and encourages intake of potassium sources in the diet. and amiloride HCL are potassium-sparing diuretics. a 3-hour oral glucose tolerance test is recommended to determine the presence of gestational diabetes. p. p. 143. A 3-hour oral glucose tolerance test 4. Introduction to medical-surgical nursing (3rd ed.. Saunders. A. Administration of NPH insulin on a daily basis 3. & Kizior. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Hodgson. Review measures to evaluate and treat elevated blood glucose levels in a pregnant client if you had difficulty with this question. Remember that spironolactone.. Administration of an oral hypoglycemic agent 2. Options 1. Spironolactone. A nurse is collecting data from a client with hypertension who is being treated with diuretic therapy.).

863. St. Murray.E. and signs of infection.E. (2002). Braxton Hicks contractions are the normal.. (2004).. D. Pork . Eggs 3. Louis: Mosby.). regular. the warning signs in pregnancy. E. & Gorrie. 42 <AQ>1776. S. change in or absence of fetal activity. (2004). severe headache.). pp. p. The nurse determines that the client needs further instruction if the client states that which of the following foods is high in potassium? 1. Maternity & women’s health care (8th ed. D. & Perry. Test-Taking Strategy: Focus on the issue. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. 145. 892.. Philadelphia: W. ___ The presence of irregular painless contractions ___Visual disturbances ___ Rapid weight gain ___ Generalized or facial edema ___Nausea on arising in the morning Answer: Visual disturbances Rapid weight gain Generalized or facial edema Rationale: Visual disturbances. persistent vomiting. Maternity & women’s health care (8th ed. review the warning signs in pregnancy.B.. S. Beef 4. pp. 1777. If you had difficulty with this question. Select the warning signs that the nurse places on the list. 351-352. S.PN~CD~Questions~1701-1800 Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum References: Lowdermilk. Raisins 2. painless contractions of the uterus that may occur throughout the pregnancy. Saunders. McKinney. abdominal pain. Louis: Mosby. Nausea on arising in the morning is a normal and expected occurrence in pregnany. premature rupture of the membranes. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Lowdermilk. Select the signs that are not a normal and expected occurrence in pregnancy.). Foundations of maternal-newborn nursing (3rd ed. & Perry. rapid weight gain. epigastric pain. Additional warning signs in pregnancy include vaginal bleeding. St. A nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the physician. T. preterm uterine contractions that are normal and regular. 359. and generalized or facial edema are warning signs in pregnancy.

Some woman may wish to rest.E.. and 4 oz of pork contain 525 mg of potassium. & Maebius. note that the incorrect instructions contains the absolute words “strict” and “avoid. A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. and they should be encouraged to do whatever feels best for them. The woman should also watch for the evidence of the passage of tissue. D. Louis: Mosby. Maternity & women’s health care (8th ed. 862. Philadelphia: W. Saunders. The woman is instructed to count the number of perineal pads used on a daily basis and to note the quantity and color of blood on the pad. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk. These words indicate a false-response question and that you need to select the item lowest in potassium. N.” respectively. Also. Four ounces of beef contain 420 mg. Test-Taking Strategy: Note the key words needs further instruction. p. S. The woman is advised to curtail sexual activities until bleeding has ceased and for 2 weeks following the last evidence of bleeding or as recommended by the physician or nurse-midwife. Test-Taking Strategy: Note the client’s diagnosis. Review therapeutic management for a threatened abortion if you had difficulty with this question. . Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton.). One half cup of raisins contains 700 mg of potassium. St. Select the instructions that relate to the diagnosis. Learn the foods that are high and low in potassium content if you had difficulty with this question. and the nurse provides a list of instructions for the client regarding management of care. (2003).PN~CD~Questions~1701-1800 - 43 Answer: 2 Rationale: One large egg provides 66 mg of potassium. Strict bed rest throughout the remainder of the pregnancy is not required.. Select the instructions that the nurse places on the list. p. (2004). ___ To maintain strict bed rest throughout the remainder of the pregnancy ___ To count the number of perineal pads used on a daily basis ___ To note the quantity and color of blood on each perineal pad ___ To watch for the evidence of the passage of tissue ___ To avoid any sexual activity for the remainder of the pregnancy Answer: To count the number of perineal pads used on a daily basis To note the quantity and color of blood on each perineal pad To watch for the evidence of the passage of tissue Rationale: The preference of the individual woman should be the deciding factor as to whether they rest in bed.B. A. & Perry. <AQ>1778. Introduction to medical-surgical nursing (3rd ed.). A threatened abortion is suspected. 162.

(2005). p. this option contains the absolute word “only. the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Review care to the intraoperative client if you had difficulty with this question.” This doctrine implies that the client would have consented to treatment if able because the alternative would have been death or disability.. Which action by the nurse is most important? 1. Asking the circulating nurse to look for the sponge Answer: 2 Rationale: The surgeon has the ultimate responsibility for the safety of the client and can stop the surgery until the sponge is found. & Perry. A. Looking on the instrument table for the sponge 4. Test-Taking Strategy: Use the process of elimination. the physician needs to be informed about the missing sponge.PN~CD~Questions~1701-1800 Murray. Additionally. Philadelphia: W. Option 1 is an unrealistic option because the client’s family may not be present. 44 1779. option 4 is standard nursing procedure regardless of the situation. S. Only if the client’s family has given consent 2. A client is brought to the emergency room and is unconscious. Although documenting is necessary. Fundamentals of nursing (6th ed. a nurse determines that emergency treatment can be initiated to the unconscious client: 1. From the viewpoint of informed consent. Options 1. p. St. Because the nurse is covered under liability insurance 4. 414. (2002). Before the surgery is completed. A surgeon is performing an abdominal hysterectomy. Saunders. 1780.B. Additionally. T. 3.). Foundations of maternal-newborn nursing (3rd ed. P. 663. E. a surgical sponge is missing. & Gorrie. review care to the client in emergency situations and the issues surrounding informed consent. .). If you had difficulty with this question. Phase of the Nursing Process: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter. and 4 are incorrect. Although options 3 and 4 may be appropriate. The emergency doctrine removes the need for obtaining informed consent before emergency treatment and care is initiated.” Options 3 and 4 are unrelated to the issue of informed consent. Informing the surgeon of the situation 3.. Noting the key words most important and recalling that the surgeon is ultimately responsible for the client will direct you to option 2. As long as the nurse documents the care given accurately Answer: 2 Rationale: Emergency treatment can be provided under the “emergency doctrine. Louis: Mosby. McKinney. this is not the most important action.. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question. Because emergency treatment can be provided under the emergency doctrine 3. Recording that the count was incorrect 2.

A nurse is caring for a home-bound older postoperative cardiovascular client. and time 2. If you had difficulty with this question. Respiratory function is impaired because of this interference with normal movements. Eliminate options 3 and 4 because they are similar positions. The lithotomy position is the one that will most likely interfere with the expansion of the lungs. and 4 identify observations that . evaluating the safety of the environment is a necessity. p.). nursing. & allied health dictionary (2002). P. The caregiver’s daughter states to the nurse. Options 1. Lateral 4. Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Mosby’s medical. The volume of air that can be inspired is reduced.). & Hogan. Caregiver leaves one side rail down while the client is in bed 3. Side lying Answer: 1 Rationale: The thoracic cage normally expands in all directions except posteriorly. 132. Fundamentals of nursing: Caring and clinical judgment (2nd ed. & Perry. Caregiver uses the overbed table for feedings Answer: 2 Rationale: Leaving a side rail down on the bed of an older client increases the risk of falling. Lithotomy 2.). St. The supine position in option 2 would not interfere with the expansion of the lungs. and 4 would not interfere with the expansion of the lungs. 1781.B. A nurse positions a client for a surgical procedure. review these positions. In the lithotomy position. A. p. 1782. (6th ed. and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Philadelphia: W. 3. Saunders. Fundamentals of nursing (6th ed. H. place. The positions in options 2.” Which observation by the nurse would indicate the need for intervention to ensure safety? 1. Potter. p. 417. (2004). 588. Louis: Mosby. St.. Client is oriented to person. Louis: Mosby. “My mother has fallen out of bed three times.PN~CD~Questions~1701-1800 - 45 Level of Cognitive Ability: Comprehension Client Needs: Safe. The aging process also increases this client’s potential for falls. (2005). Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Harkreader. M. Test-Taking Strategy: Use the process of elimination and visualize each position and its effect on lung expansion. Supine 3.. 3.A. therefore eliminate this option. Client’s bed is in a low position 4. Which position can most likely lead to the potential for decreased lung expansion in the client? 1. the expansion of the lungs is restricted at the ribs or sternum.

A. This nurse is most likely to react to a disagreement with this fellow employee by: l.). Fundamentals of nursing: Caring and clinical judgment (2nd ed. A nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. If you had difficulty with this question. Review the causes of falls in an older client if you had difficulty with this question. and note the key words need for intervention to ensure safety. 1783.). Getting angry at the supervisor 4. Fundamentals of nursing (6th ed. Daily cold therapy has been prescribed for the client. Apologizing and offering to go out to lunch together Answer: 2 Rationale: The defense mechanism of projection is an unconscious process that projects emotionally unacceptable feelings to other people. A nurse is assisting in preparing a client for discharge to home. 499. Which statement by the client indicates adequate understanding of cold therapy treatment? 1. review defense mechanisms.. “I need to apply the cold pack for at least 60 minutes. or situations and casts the blame onto another. and the nurse reinforces instructions with the client about this treatment. an unsafe observation. Level of Cognitive Ability: Comprehension Client Needs: Safe. P. objects. M. Philadelphia: W. pp. “I should wrap the frozen ice pack in a warm towel to help adjust to the cold. Potter. Option 4 describes reaction formation in which a behavior is used that is directly opposite to a person’s unacceptable trait. 1784.. 490-491. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader. Focus on the issue. Options 1 and 3 describe displacement in which the feeling is transferred to another person or object. which would reduce the risk of falling. Test-Taking Strategy: Use the process of elimination focusing on the issue. Test-Taking Strategy: Knowledge of the defense mechanisms is needed to select the correct option. p. Slamming cupboards in the office 2. & Hogan. St.A. (2004). (2005). H. and identify the defense mechanism that corresponds to the example presented in the situation.B.B.PN~CD~Questions~1701-1800 - 46 provide safety to the client. projection. & Hogan. pp. H. 964-965. M. 1155.” 2. Saunders. Fundamentals of nursing: Caring and clinical judgment (2nd ed. Saunders. Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Harkreader. Louis: Mosby..” 3. (2004).” . Telling a friend that this employee hates her or him 3.). & Perry. Philadelphia: W. “I can lay on the ice by placing it between the bed and my body. Option 1 indicates that the client is oriented.A. Options 3 and 4 also identify a safe and appropriate environment.

McKinney.” Answer: 1 Rationale: Before conception.” 2. (2004). & Potter. Saunders. Perry. 640. eliminate option 4 because it is not reasonable and is unnecessary. St.B.). placenta. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Murray. The weight of the body and the low temperature of the ice may produce ischemia.A.” 3. Which response by the student indicates an understanding of the anatomy of this structure? 1. Remember that before pregnancy. T. & Gorrie. At the end of pregnancy. The frozen ice pack is taken from the freezer and should be wrapped in a warm towel to help the client adjust to the cold.PN~CD~Questions~1701-1800 - 47 4. Review the anatomical structure of the uterus if you had difficulty with this question. the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL. The skin should be checked for signs of injury. 605-609. Nursing interventions and clinical skills (3rd ed. P. Saunders. E. the uterus weighs approximately 1000 g (2. Louis: Mosby.. Test-Taking Strategy: Note the key word nonpregnant and attempt to visualize each of the items identified in the options. Test-Taking Strategy: Use the process of elimination and visualize the procedure. 120... and amniotic fluid. “The uterus weighs about 2 oz.B. A nurse is caring for a new postoperative client and is monitoring the client for . (2004). 597. S. pp. “The uterus has a capacity of about 50 mL. & Hogan. 1786. M. (2002). p.).” Answer: 3 Rationale: Cold therapy should only be used for 15 to 20 minutes two or three times a day. A. The client needs to be instructed not to place ice directly between the skin and a firm surface. Next. “I should check my pulse before using the ice on my joints. a total of about 5000 mL. “The uterus weighs about 2. the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. Philadelphia: W.” 4.). Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Elkin. “The uterus is round in shape and weighs approximately 1000 g. This should help you eliminate options 1 and 2. Before pregnancy. If you had difficulty with this question. p. Fundamentals of nursing: Caring and clinical judgment (2nd ed.. Foundations of maternalnewborn nursing (3rd ed. review the procedure for cold pack therapy. H.2 lb) and has a sufficient capacity for the fetus.2 lb. A nursing student is asked to describe the size of the uterus in a nonpregnant client. M. 1785. Philadelphia: W. Harkreader. the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL..

and hypotension 4. and fluid or blood loss. Philadelphia: W. moist. “It probably isn’t strabismus. p. pale. Philadelphia: W. Remembering that a drop in blood pressure and a rise in pulse are indicative of shock will direct you to the correct option. or cyanotic skin. . The registered nurse asks the student to interpret the finding.” 2.). cold. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: deWit. irritability. (2005). drowsiness. (2004). and restlessness Answer: 3 Rationale: Postoperative hypotension or shock can have numerous causes. If you had difficulty with this question. and Alaskan-Native infants often have a pseudostrabismus because of a flattened nasal bridge. 750. “It probably is strabismus because the baby’s mother has abused tranquilizers.B. and rapid respirations 3. “You will want to call the pediatrician immediately because this could lead to a detached retina.” Answer: 1 Rationale: Asian-American. Which statement by the student indicates an understanding of this finding? 1. and hypertension 2. but appears that way because of the child’s ethnic background. Review these differences if you had difficulty with this question. warm skin. 1787. Cold skin. such as inadequate ventilation. review the signs of shock. and 4 are inaccurate statements. A student nurse examines an Asian-American infant’s eyes and notes that the infant’s eyes are crossed. The manifestations of shock include hypotension.B. p. 3. Saunders. but it requires surgery in the first 2 months to prevent the crossed eyes from being a lifelong condition.” 3.PN~CD~Questions~1701-1800 - 48 signs of shock. American-Indian. Physical examination and health assessment (4th ed. Test-Taking Strategy: Use the process of elimination. Options 2. all parts need to be correct for the option to be the answer to the question. and increased restlessness and apprehension. cold skin. side effects of anesthetic agents or preoperative medications. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Jarvis. S. The nurse monitors for which signs of this postoperative complication? 1. Fever. Remember that when an option contains more than one part. C. It will need to be distinguished from a true strabismus in the assessment. 323. “Strabismus isn’t life threatening. Saunders. Tachycardia. Test-Taking Strategy: Use the process of elimination.” 4. tachycardia. Recalling the cultural differences in the physical assessment findings in an infant will direct you to option 1. Fundamental concepts and skills for nursing. Slow pulse.

St. 18. Focus on the weeks of gestation identified in the question to assist in directing you to the correct option. Louis: Mosby. By 36 weeks. Defined as a crime that results in the injury of a client 3. At 16 weeks. it was determined that the nurse failed to check the client’s identification bracelet before administering the medications. A. Test-Taking Strategy: To answer this question correctly. If you had difficulty with this question. but the words “strictly prohibited” tends to make these options incorrect. select option 1 because it is the umbrella (global) option. although injury may have indeed come to the client as a result of negligence. review the concepts related to negligence. 1789. 283. Both the institution and the Nurse Practice Act have provisions that identify and discourage acts of negligence.). the fundus reaches midway between the symphysis pubis and the umbilicus. Test-Taking Strategy: Knowledge regarding the patterns of uterine growth is required to answer this question. 414. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Harkreader. Options 3 and 4 are true in that the purpose of the Nurse Practice Act and institutional policies and procedures is to protect the public from harm. During the investigation of the incident. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity . At 20 weeks. Just above the symphysis pubis 2. A nurse is reviewing the health care record of a pregnant client at 16 weeks’ gestation. the fundus reaches its highest level at the xiphoid process. M. & Hogan. Strictly prohibited by the institution’s own policies Answer: 1 Rationale: The legal definition of negligence is the failure to meet accepted standards of care. At the level of the xiphoid process Answer: 3 Rationale: At 12 weeks’ gestation. Saunders. Strictly prohibited by the Nurse Practice Act 4. At the umbilicus 3.. & Perry. The nurse would expect documentation that the fundus of the uterus is noted at which of the following areas? 1. review this content. pp. Defined as the failure to meet established standards of care 2.). From the remaining options. (2005). you must know the definition of negligence as applied to the profession of nursing. Fundamentals of nursing (6th ed. Midway between the symphysis pubis and the umbilicus 4. p. H. P. the fundus is located at the umbilicus.B.A. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is: 1. If you are unfamiliar with the patterns of uterine growth during pregnancy. Potter. the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis.. Philadelphia: W. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed. A nurse administers medications to the wrong client.PN~CD~Questions~1701-1800 - 49 1788. Option 2 is an incorrect definition of negligence.

Philadelphia: W. Foundations of maternal-newborn nursing (3rd ed. Compare these values with those recorded previously 3. Correct use requires a spontaneous. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client should not be holding the breath following inhalation Answer: 2 Rationale: Incentive spirometer devices use a concept of sustained maximal inspiration. T. Noting the key words takes one breath and returns the incentive spirometer to the bedside and visualizing this procedure will direct you to option 2.. p. & Perry. When full inhalation is reached. Recheck the blood pressure in 5 minutes 4. review the correct procedure for the use of an incentive spirometer. Each device has a means of setting an inspiratory goal. E. Louis: Mosby. St. S. what interpretation should the nurse make? 1.). Based on the interpretation of these findings. The client should be inhaling and exhaling quickly 4.PN~CD~Questions~1701-1800 Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk. voluntary.. Saunders. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Perry. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds and then exhales slowly. and blood pressure 168/94 mm Hg in the right arm. Louis: Mosby. Incentive spirometer exercises are most effective when used every hour while the client is awake. Test-Taking Strategy: Use the process of elimination focusing on the client’s performance described in the question. Report only the apical pulse since it is above the normal range Answer: 2 Rationale: Preoperative assessment of vital signs provides important baseline data with which to compare following surgery.. Based on this observation. & Potter. apical pulse 80 beats/min with a regular rhythm. St. D.).B. pp. The client should be repeating the sequence 10 to 20 times in each session 3.). Maternity & women’s health care (8th ed. A. (2004). & Gorrie. deep breath. the breath is held for at least 3 seconds. The vital signs as stated in the question do not need to be . This sequence is repeated 10 to 20 times an hour.E.. If you had difficulty with this question. Anxiety and fear commonly cause elevations in the heart rate and blood pressure. McKinney. which of the following actions should the nurse take first? 1. 350-351. P. Murray. respiration rate 22 breaths per minute. (2002). 425. slow. Clinical nursing skills & techniques (5th ed. (2004). 1791.6° F orally. A postoperative client is using an incentive spirometer. pp. A client’s preoperative vital signs are temperature 98. 50 1790. Report the vital signs immediately to the registered nurse (RN) 2. S. 327-329. The client is using the incentive spirometer correctly 2. The client takes one breath and returns the incentive spirometer to the bedside.

Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit. S. 149. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk. Louis: Mosby. Adding 1 tbsp of mineral oil to a bowl of cereal daily Answer: 4 Rationale: Mineral oil should not be used as a stool softener since it inhibits the absorption of fat-soluble vitamins in the body. Saunders. In addition to the intravenous infusion. T.. The apical pulse is not above the normal range. pp. Note that options 1. 390. Constipation should be treated with increased fluids (six to eight glasses per day) and a diet high in fiber.. Recalling the normal ranges for vital signs and the effects of anxiety and fear on the vital signs in the preoperative client will direct you to option 2. Maternity & women’s health care (8th ed. Philadelphia: W. Increasing whole grains and fresh vegetables in the diet 4. A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Test-Taking Strategy: Use the process of elimination noting the key words a harmful measure. Review care to the preoperative client if you had difficulty with this question. 1792. The nurse should compare these values with those recorded previously. McKinney. These words indicate a false-response question and that you need to select the incorrect intervention for treating constipation.. Focus on the data in the question and note that the client is preoperative. review measures to prevent constipation. Drinking six to eight glasses of water daily 3. A client has an intravenous infusion (IV) started before surgery for a right belowthe-knee amputation.B.PN~CD~Questions~1701-1800 - 51 reported to the RN immediately. such as walking or swimming 2. Test-Taking Strategy: Use the process of elimination noting the key word first. S. St.). (2004). Option 4 is an unnatural measure and needs to be avoided. S. Philadelphia: W. p.E. & Gorrie. Murray. Saunders. 744.). 433. blood work is drawn and a . E. D. Increasing exercise is also an excellent way to improve gastric motility. Daily activity. Which of the following would the nurse determine is a harmful measure in preventing constipation? 1. 2. Foundations of maternal-newborn nursing (3rd ed. and 3 are natural methods for increasing gastric motility.B. (2002). & Perry. Fundamental concepts and skills for nursing. p. 1793. Rechecking the blood pressure in 5 minutes is likely to show an unchanged blood pressure measurement. (2005). The first action should be to compare the values with those recorded previously. If you had difficulty with this question.

Which nursing diagnosis is most appropriate for the nurse to consider in providing preoperative care? 1.B. are used to replace fluid from gastrointestinal (GI) tract losses. Deficient fluid volume related to IV therapy 2. Albumin is used for shock and protein replacement. Test-Taking Strategy: Use the process of elimination noting that the client is 1 day postoperative. & Potter. 1219. Nursing interventions and clinical skills (3rd ed. If you had difficulty with this question. Five percent dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Louis: Mosby. Knowledge of the components of IV solutions and noting that the client had GI surgery will direct you to option 3. Perry. Postoperative concerns. (2004).). 492. Client anxiety is a priority concern before surgery and when treatments are performed. review the components of these IV solutions. should be addressed in the preoperative period. p. 1794.).. A. Risk for excess fluid volume related to IV therapy 3. and has continuous gastric suction attached to the nasogastric tube. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Elkin. (2004). M. 25% albumin 2.A.. A nurse is caring for a client who had a small bowel resection. There is no data in the question to indicate signs of actual fluid volume deficit or overload. St. Fundamentals of nursing: Caring and clinical judgment (2nd ed. Anxiety related to coping with preoperative therapies Answer: 4 Rationale: Before surgery most clients experience anxiety. Noting the key words prior to surgery will direct you to option 4. such as acute pain. Harkreader. Which of the following intravenous solutions would the nurse anticipate would most likely be prescribed for the client? 1. M. such as lactated Ringers. 5% dextrose in water 3.PN~CD~Questions~1701-1800 - 52 surgical skin preparation is done. and glucose is essential for calories when a client is NPO. H. is 1 day postoperative. Review the defining characteristics for anxiety if you had difficulty with this question. & Hogan. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning . Normal saline contains no glucose. Normal saline Answer: 3 Rationale: Electrolyte solutions. Lactated Ringers solution 4. Saunders. Philadelphia: W. Remember to focus on the client concerns as a priority in the preoperative period. but this is not the issue of the question. P.. Acute pain related to surgery 4. p. Test-Taking Strategy: Use the process of elimination focusing on the data in the question.

p. 1796. Review care to the client following nephrectomy if you had difficulty with this question. Louis: Mosby.PN~CD~Questions~1701-1800 Content Area: Fundamental Skills References: Black. E.. Louis: Mosby. Help reduce the cost of the preoperative work-up 4. & Perry. 446. A client is being evaluated as a potential kidney donor for a family member. The psychosocial issues in living-related organ donation may be very complex. (2005). & Hawks. To avoid conflict of interest.. 1160. A nurse is urging a client to cough and deep breathe after nephrectomy. evaluation of the donor is done by a team different from that caring for the donor.B. A latent fear of needing dialysis if the surgery is unsuccessful 3. Medical-surgical nursing: Clinical management for positive outcomes (7th ed. p. & Kockrow. .). narcotics are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. p. (2005). The donor asks the nurse why a different team of people is doing the evaluation. For this reason. In formulating a response. Adult health nursing (4th ed. Recalling that coughing and deep breathing intensifies pain after many surgical procedures and visualizing the location of the surgical incision will direct you to option 4. Philadelphia: W. Test-Taking Strategy: Use the process of elimination noting the key words most likely. and conversations with the donor are held in strict confidence to preserve family relations. St. which makes coughing and deep breathing so uncomfortable. This is due to the size of the incision and its location near the diaphragm. “That’s easy for you to say! You don’t have to do this. Pain that is intensified because the location of the incision is near the diaphragm Answer: 4 Rationale: After nephrectomy the client may be in considerable pain.. 53 1795. 2. A.). Fundamentals of nursing (6th ed. Save the client and recipient valuable preoperative time 2. the nurse understands that this is being done to: 1. Saunders. (2003). Effects of circulating metabolites that have not been excreted by the remaining kidney 4. J. Options 1.). B. J. A stress response to the ordeal of surgery 2. 210. St. and 3 are not specifically related to this client’s situation.” The nurse interprets that the client’s statement is most likely a result of: 1. Prevent a conflict of interest by the team evaluating the recipient and team evaluating the donor 3. P. The client tells the nurse. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Christensen. Potter. Have a sufficient number of people reviewing the case so no information is overlooked Answer: 2 Rationale: Both the kidney donor and recipient need thorough medical and psychological evaluation before transplant surgery.

. like that of breast engorgement. Remember that in this situation one group cannot advocate for both parties simultaneously. D. Maternity & women’s health care (8th ed. Oxytocin 3. J. Document the findings 3. review normal newborn findings.). A nurse is assisting in conducting a prenatal session with a group of expectant parents. A nurse is changing the diaper of a 1-day-old. Saunders. The mucus is occasionally blood tinged by about the third or fourth day and stains the diaper.. Notify the registered nurse immediately 4. Testosterone 2. Louis: Mosby. & Gorrie. A vaginal discharge of thick white mucus is seen in the first week of life.PN~CD~Questions~1701-1800 - 54 Test-Taking Strategy: Use the process of elimination and knowledge of concepts regarding client advocacy. 1798. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is: 1. Obtain a specimen of the discharge for culture 2. If you had difficulty with this question. Review the mother’s record to determine a history of gonorrhea Answer: 2 Rationale: The genitalia of a newborn female are frequently red and swollen. Medical-surgical nursing: Clinical management for positive outcomes (7th ed. The cause of the pseudomenstruation. Saunders. St. If you had difficulty with this question. 1797.B. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Prolactin 4. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Renal Reference: Black. Recalling that the findings noted in the question are normal and expected will direct you to option 2.). Foundations of maternal-newborn nursing (3rd ed. p. S. E. full-term female newborn and notes that the genitalia is red and swollen and that a thick white mucoid vaginal discharge is present. 529. the nurse determines that the best action would be to: 1. Based on these findings. T. Philadelphia: W. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Lowdermilk. review the concepts related to organ donation. (2004).. (2005). p. 688. 2435. & Hawks. A. & Perry. p. Progesterone Answer: 3 . (2002). This edema disappears in a few days. Philadelphia: W. J.). is the withdrawal of maternal hormones. Murray.B. McKinney..

If the client does not seem to understand what is said. The nurse would intervene if which of the following were performed by the nursing assistant during communication with the client? 1. Use the process of elimination recalling that the nurse needs to avoid talking directly into the impaired ear.). review the functions of the various hormones of the female reproductive system. (2002). The nurse should talk directly to the client while facing the client and speak clearly. Philadelphia: W. Level of Cognitive Ability: Comprehension Client Needs: Safe.). Test-Taking Strategy: Knowledge regarding the functions of the various hormones in the female reproductive system is required to answer this question. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.PN~CD~Questions~1701-1800 - 55 Rationale: Prolactin stimulates the secretion of milk. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills References: Lowdermilk. & Kockrow. St. If you had difficulty with this question. (2003). This word indicates a false-response question and that you need to select the incorrect action by the nursing assistant. the nurse should speak in a normal tone to the client and should not shout. & Gorrie. 70. Note the relation between the words “secretion of milk” in the question and the hormone “prolactin” in the correct option.. T. Adult health nursing (4th ed.B. S. Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Christensen. but the nurse needs to avoid talking directly into the impaired ear. Moving closer to the client and toward the better ear may facilitate communication. Progesterone stimulates the secretions of the endometrial glands. B. Foundations of maternal-newborn nursing (3rd ed. E. 1800. A clinic nurse is providing instructions to a client regarding the use of a hearing . Test-Taking Strategy: Note the key word intervene. The nursing assistant is speaking in a normal tone Answer: 3 Rationale: When communicating with a hearing-impaired client. If you had difficulty with this question. Louis: Mosby.. The nursing assistant is speaking directly into the impaired ear 4. causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. (2004). Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. D. The nursing assistant is speaking clearly to the client 3. called lactogenesis. A nurse is observing a nursing assistant talking to a client that is hearing impaired. Murray. p. E. 1799.).. 587. McKinney.E. & Perry. p. St. Maternity & women’s health care (8th ed. review these techniques. The nursing assistant is facing the client when speaking 2.. p. the nurse should express the statement differently. Louis: Mosby. 762. S. Saunders.

“I should not wear the hearing aid during an ear infection.” 2. “I should keep an extra battery available at all times. These words indicate a false-response question and that you need to select the incorrect client statement. review client instructions regarding the use of the hearing aid. If you had difficulty with this question. The client should wash the ear mold frequently with mild soap and water with the use of a pipe cleaner to cleanse the cannula. p. St. 586. (2003).).. Adult health nursing (4th ed. and the client should keep an extra battery available at all times. “I should turn the hearing aid off after removing it from my ear.PN~CD~Questions~1701-1800 - 56 aid. “I should wash the ear mold frequently with mild soap and water.” 4. The client should not wear the hearing aid during an ear infection. B. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback.” Answer: 3 Rationale: Nurses should have a basic knowledge of the care of a hearing aid to assist the client in its use. E. Louis: Mosby.” 3. Which statement by the client indicates a need for further instructions? 1. Test-Taking Strategy: Use the process of elimination noting the key words need for further instructions. The hearing aid should be turned off when not in use. & Kockrow. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Christensen. Knowledge regarding squealing feedback will assist in directing you to the correct option. .

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