The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadt

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysisThe reports nausea, vomitingand scant dark brown vaginal discharge Which action should the nurse take? A Recommend bed rest B Collect urine sample for urinalysis C Obtain human chorionic gonadatropin D levels Measure vital signs Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect A Disrupted surfactant production B Aphasia and memory loss C Deep sleep or coma D Metabolic acidosis The nurse is caring for a with a suspected diagnosis of . Which diagnostic test should the nurse prepare the to expect the provider to prescribe ? A Erythrocyte sedimentation rate B Radiographs C C-reactive protein test. D Radionuclide bone scan. A client who is on complete bedrest frequently call the nurse for the bedpan to urinate Which action should the nurse take to evaluate the client for urinary retention? A Palpate the suprapubic region for distention B Review the chart for number of voids over last 24 hours Scan the client’s bladder after voiding D. Evaluate the client for urinary incontinence A client who is 37 weeks gestation comes to the women’s health clinic reporting an excruciating headache . On examination , the nurse determines the client has an elevated blood pressure . Which action should the nurse implement next ? A Ask about a history of delivering large babies . B Examine the client for pedal edema . C Collect a urine sample to screen for protein D Establish the frequency of headaches A preschool – aged gin tells the school nurse that her hair hurts. The nurse finds that the child’s hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related? A Episodic complaints of pruritus B Ecchymotic blood accumulations C Evidence of patches of lost hair D Erythema of the localized lesions The parents of a 14- month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures Which Information should the nurse convey to these parents ? A. Ibuprofen should be used prophylactically to prevent febrile seizures BReassure the parents that febrile seizures decrease as the child grows older . C Provide the child with a sponge bath for temperatures over 100.6 F (38.1 C) D Avoid excessive visual stimuli because it can precipitate seizure activity Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect? A Disrupted surfactant production B Aphasia and memory loss C Deep sleep or coma D Metabolic acidosis The nurse is teaching an older male client who lives alone and has minimal memory loss about a newly prescribed medicationWhich actions would the nurse take? (Select all that apply) A Provide printed materials about medication actions and side effects B Ask the client to repeat back the medication information C Teach family about administration of the medication D Assess for possible sensory deficits before beginning teaching E Provide a quiet , calm environment when teaching When preparing a for a paracentesis, which action is most important to delegate to the unlicensed assistive personnel UAP) who is assisting the A Measure the client’s abdominal girth B Obtain the client’s current weight C Assist the client to emply bladder D Determine when the client last ate An older adult is admitted to the intensive care unit with a diagnosis of hyperosmolar hyperglycemic state (HHS) A sliding scale protocol for an isotonic V solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client’s central venous catheter Which interventions should the nurse include in this client’s plan of care? (Select all that apply) A. Adjust infusion rate based on continuous glucose monitoring B Assess for tachycardia , pallor , and changes in mental status C Monitor the client for pain in the abdomen , chest , and back D Obtain blood culture specimens every 24 hours for 3 days E Auscultate the lungs for crackles and observe for dyspnea following a left spontaneous pneumothorax, a chest tube is inserted into the client’s left lung pleural space. The nurse observes continuous bubbling in the water seal chamber and informs the health care provider that the client has a constant air leak. When transporting the client for a computerized tomography (CT) scan, which action should the nurse implement? a. Maintain the tube drainage device below the level of insertion b. clamp the tube in two places with blunt tipped hemostats c. milk the tube immediately prior to transporting from the unit d. reinforce the dressing around the chest tube’s exit site the nurse is planning care for a client who has had a suprapubic resection of the prostate gland. Which nursing problem has the highest priority for this client’s care? A Impaired physical mobility related to multiple devices B risk for fluid volume related NPO status C pain related to inability to use patient controlled anesthesia D risk for decreased cardiac output related to bleeding a client who was hospitalised and recently diagnosed with Addison’s disease is now confused and lethargic. Which actions should the nurse implement? a. withhold next dose of corticosteroids b. initiate fall risk precautions c. monitor cardiac telemetry pattern d. measure capillary glucose level e. reduce rate of intravenous fluid infusion A male client who is HIV positive is seen in the clinic for a routine physical examination. He is taking the reverse transcriptase inhibitor medication lamivudine is most important for the nurse to notify the healthcare provider of which A. client finding States he drinks a glass of wine nightly to help him sleep . B Abdominal pain and elevated liver function tests (LFTs ) C. Hemoglobin of 9 gram/and complaints of fatigue D. Reports no incidents of infection since taking lamivudine A male client with heart failure becomes short of breath, anxious and has audible wheezing with pink frothy sputum. The nurse hits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one time dose of morphine sulfate intravenously. What action should the nurse take? A Review the need for the prescription with the health care provider B withhold the morphine until the client’s dyspnea resolves C consult with the charge nurse regarding the morphine prescription D administer the dose of morphine sulfate as ordered A client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation in the advanced cardiac life support team defibrillate’s the client, restoring a normal sinus rhythm. Later that day, a family member questions why the code was called, telling the nurse if the client has a living will. How should the nurse respond? A Check the client’s arm for a do not resuscitate bracelet B seek clarification of the type of advance directive the client has C schedule a client and family conference to review the plan of care D explain that living wills cannot be followed by emergency personnel At 0100 on a male client’s second postoperative night , the states he is unable to sleep and plans to read until feeling sleepy What action should the nurse implement ? A Leave the room and close the door to the client’s room B Discuss symptoms of sleep deprivation with the client C Assess the appearance of the client’s surgical dressing D Bring the client a prescribed PRN sedative -hypnotic for a renal biopsy. What information about purpose of the renal biopsy should the nurse share with the parents? A Differentiate the type of dialysis most beneficial for the child B evaluate the extent of the disease and need for kidney transplant C identify the type of nephorotic syndrome, its course, and best treatment D determine if the disease has a genetic basis


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