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NEW QUESTION 234
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:
- A. Administer methergine IM
- B. Assist the client to the bathroom and provide cues to stimulate urination
- C. Remove the retained placental fragments
- D. Massage the fundus until firm
Answer: D
Explanation:
(A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
NEW QUESTION 235
A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
- A. Auscultate the lung to determine if she needs the tube replaced
- B. Instruct the client to cough deeply to re-expand her lung
- C. Put on sterile gloves and replace the tube
- D. Apply a petrolatum dressing over the site
Answer: D
Explanation:
Explanation
(A) This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further treatment. (D) The decision to reinsert the tube is a medical decision, not a nursing one.
NEW QUESTION 236
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction.
One comfort measure the nurse can employ is to:
- A. Have her push with each contraction
- B. Use effleurage during the contraction
- C. Place her in knee-chest position during the contraction
- D. Apply strong sacral pressure during the contraction
Answer: D
Explanation:
Explanation
(A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. (B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head. (D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor.
NEW QUESTION 237
During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the child's change in behavior?
- A. A lack of interest in socializing
- B. A coping response
- C. Deep-seated feelings of hostility
- D. Usual behavior for this child
Answer: B
Explanation:
(A) Unusually aggressive behavior does not indicate a deepseated problem. (B) A lack of social interest results in poor participation in play activities with peers. Aggression would not be an expected behavior. (C) The aggressive behavior was newly developed and not a routine behavior. (D) Play provides the child with opportunities for coping and adaptation. Aggression during the play activities would indicate a coping response.
NEW QUESTION 238
A dose of theophylline may need to be altered if a client with COPD:
- A. Is concurrently on cimetidine for ulcers
- B. Is allergic to morphine
- C. Has a history of arthritis
- D. Operates machinery
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity.
NEW QUESTION 239
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
- A. Increased breath sounds on the affected side
- B. Crackles or rales on the affected side
- C. Bradypnea and bradycardia
- D. Shortness of breath and sharp pain on the affected side
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
NEW QUESTION 240
What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?
- A. Human chorionic gonadotropin
- B. α-fetoprotein
- C. Sphingomyelin
- D. Estrogen
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Human chorionic gonadotropin is the biochemical basis for pregnancy tests. It is produced by the placenta to help maintain the corpus luteum. Its levels climb rapidly following conception, peaking at about 8 weeks and then gradually decreasing to low levels after 16 weeks. (B) Estrogen does steadily rise throughout pregnancy, increasing to 30 times that of prepregnancy levels. Although estrogen levels do change during pregnancy, it is not used as the main hormone of evaluation in pregnancy tests. (C) α-Fetoprotein is the major protein in the serum of the embryo. It is initially produced by the yolk sac. (D) Lecithin and sphingomyelin are two phospholipids of which fetal lung surfactant is composed. Levels are evaluated to determine fetal lung maturity.
NEW QUESTION 241
A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being "bugged." Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:
- A. Supervise her medication regimen
- B. Involve her in groups for social interaction
- C. Protect her from suicide
- D. Enable her to develop trust
Answer: D
Explanation:
Explanation
(A) Suicide is a greater risk in depression than in schizophrenia. (B) The client is suspicious and needs help to develop trust, which is basic to her improvement. (C) Although she will be taking medication, drug therapy would not necessitate consistency in the nurses assigned. (D) A suspicious client should have limited exposure to groups, because group participation increases discomfort.
NEW QUESTION 242
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
- A. Lung immaturity
- B. Intrauterine infection
- C. Neural tube defect
- D. Intrauterine growth retardation (IUGR)
Answer: A
Explanation:
(A) At about 30-32 weeks' gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _-fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly.
NEW QUESTION 243
A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?
- A. Low calcium and phosphorus, acid ash
- B. High calcium, low phosphorus
- C. Two-gram sodium diet
- D. Low calcium, high phosphorus
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A high- calcium diet is contraindicated. (B) A high-phosphorus diet is contraindicated. (C) A 2-g sodium diet is a cardiac diet. (D) A low-calcium and phosphorus diet will reduce further calculi formation.
NEW QUESTION 244
An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:
- A. They need to mix it with formula so the infant swallows it easily
- B. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the physician
- C. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed
- D. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose
Answer: B
Explanation:
(A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled.
NEW QUESTION 245
A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
- A. Report to the surgeon if the client is unable to void within 8 hours of surgery
- B. Provide food and fluids at the client's request
- C. Maintain IV, increasing the rate hourly until the client voids
- D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention
Answer: A
Explanation:
(A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
NEW QUESTION 246
A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:
- A. Delusions of grandeur
- B. Delusions of persecution
- C. Ideas of reference
- D. Thought broadcasting
Answer: A
Explanation:
Explanation
(A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
NEW QUESTION 247
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Mafenide acetate
- B. Neosporin sulfate
- C. Silver sulfadiazine
- D. Povidone-iodine
Answer: A
Explanation:
Section: Questions Set A
Explanation:
(A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone-iodine is decreased renal function.
NEW QUESTION 248
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
- A. Increases venous return and cardiac output by normalizing fluid status
- B. Covers burn scars and decreases the psychological impact during recovery
- C. Decreases hypertrophic scar formation
- D. Assists with ambulation
Answer: C
Explanation:
Explanation
(A) Tubular support, such as that received with a Jobst garment, applies tension of 10-20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6-12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
NEW QUESTION 249
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:
- A. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area
- B. Tip of the nose to the lower lip to the umbilicus
- C. Lower lip to the shoulder to the upper sternum
- D. End of the tube to the first measurement line on the tube
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) This measurement is 50 cm (48-49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is 50 cm (47-48 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement).
It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.
NEW QUESTION 250
The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:
- A. Month-old magazines that are provided by volunteers
- B. A litter of kittens for the clients to pet
- C. Large maps and posters depicting area of current residence
- D. A library of biographical books
Answer: C
Explanation:
(A) This answer is incorrect. Current magazines would be appropriate. (B) This answer is correct. Maps of the state and town and posters that depict current events in the area are appropriate props. (C) This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy. (D) This answer is incorrect. Biographies depict a past, not a present, orientation.
NEW QUESTION 251
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