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70 Cards in this Set

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A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is requesting some water. The nurse must:
C. Check the gag and swallowing reflexes.
A. Keep the client NPO until an order is written.
B. Check the vital signs first.
C. Check the gag and swallowing reflexes.
D. Encourage coughing and deep breathing.
A client is placed on seizure precautions. The nurse knows that an appropriate intervention for a grand mal seizure is:
D. Place the head in a lateral position.
A. Insert a tongue blade between the teeth to prevent biting the tongue.
B. Apply restraints to prevent injury to the self.
C. Place the client in a supine position.
D. Place the head in a lateral position.
A 15-year old client fractured his tibia and several metatarsal bones. A cast has been applied; it extends from the knee to the toes. The nurse makes frequent assessments of which of the following:
B. Color, temperature and sensation in the toes.
A. Quality of the popliteal and femoral pulses.
B. Color, temperature, and sensation in the toes.
C. Movement of the toes on both feet.
D. The pedal pulses in both lower extremities.
A client is in traction for a fractured femur. Which of the following statements indicates understanding of the nurse's instruction:
A. The weights must hang freely at all times
A. The weights must hang freely at all times.
B. I'm free to move about in bed as I wish.
C. I'll be in a lot of pain and will need narcotics frequently.
D. I won't have the time or energy to work on my paintings.
A 45-year old client is receiving heparin sodium for a pulmonary embolus. The nurse evaluates which of the following laboratory reports of partial thromboplastin time as indicative of effective heparin therapy?
C. Two to 2.5 times the control (normal) value.
A. Within nomral range
B. One to 1.5 times the control (normal) value
C. Two to 2.5 times the control (normal) value
D. Three times the control (normal) value.
A client is on intravenous heparin therapy. The nurse would keep which of the following drugs available as an antidote.
B. Protamine Sulfate
A. Vitamin K
B. Protamine Sulfate
C. Epinephrine
D. Norepinephrine
A client is taking warfarin (Coumadin) following placement of an artificial mitral valve. The nurse instructs the client to avoid taking the following commonly used drugs:
D. Aspirin
A. Maalox Plus
B. Tylenol Cold & Flu Medication
C. Sudafed
D. Aspirin
During the evening following a partial gastrectormy, a client's oral temperature is 100F. Other data include a blood pressure of 134/68, a pulse of 88, and a respiratory rate of 18. The nurse should:
B. Take the temp every hour until it is normal.
A. Notify the physician immediately
B. Take the temp every hour until it is normal.
C. Perform a thorough Respiratory assessment.
D. Remove the dressing and check the operative site.
A client with insulin-dependent diabetes mellitus (IDDM) is being discharged. The nurse knows that the client has understood essential teaching when the following statement is heard:
A. I need to cut my nails straight across.
A. I need to cut my nails straight across.
B. I can't make any substitutions in my diet.
C. My insulin should be given into my arms.
D. I should eat less before exercising.
A 45-year old client has recently been told that she has acute nyelocytic leukemia. She seems quite happy and laughs and jokes about everything. The nurse should:
C. Wait and allow her to explore her feelings.
A. Remind her of the seriousness of her diagnosis.
B. Encourage her to continue with her laughter and joking.
C. Wait and allow her to explore her feelings.
D. Reprimand her for not taking her treatment seriously.
A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the following laboratory test daily:
A. Complete blood count
A. Complete blood count.
B. Electrolyte panel
C. Prothrombin Time
D. Blood urea nitrogen and creatinine
A client has developed depression of the bone marrow from antineoplastic drugs. The nurse states the nursing diagnosis of highest priority as:
D. High risk for infection
A. Fluid volume deficit
B. High risk for aspiration
C. Ineffective thermoregulation
D. High risk for infection
Radioactive iodine is being used to treat a client with cancer of the thyroid gland. The nurse knows that the client has understood teaching about the treatment when the following statement is heard.
D. My body fluids will be radioactive for a short time.
A. Only my thyroid gland will be radioactive.
B. I need not be concerned about radioactivity
C. My whold body will be radioactive.
D. My body fluids will be radioactive for a short time.
A radioactive implant is being used to treat a client with cancer of the prostate. The implant is found on the floor near the patient. The nurse should:
B. Place the implant in a radiation-proof container, using forceps
A. Replace the implant, using forceps.
B. Place the implant in a radiation-proof continaer, using forceps.
C. Leave the implant for the radiation safety officer.
D. Place a lead shield between the nurse and the implant.
A nurse assess an intravenous site of a client and finds it red, swollen, and painful; there is no blood return. The nurse should:
A. Remove the IV at once
A. Remove the IV at once.
B. Watch to see if the swelling gets worse
C Report it to the physician
D. Apply an antibiotic ointment to the site.
A client's total parenteral nutrition is 6 hours behind schedulel. The nurse would
D. Check the blood glucose level.
A. Run the fluid at a rate to make up for the lost time.
B. Report the situation to the physician.
C. Run the IV at the prescribed site.
D. Check the blood glucose level.
A 44-year old client is in acute congestive heart failure. THe nurse and client establish a goal of highest priority as:
A. rest mentally as well as physically
A. Rest mentally as well as physically
B. Learn stress management
C. Train for a less demanding job.
D. Prevent complications of immobility
A 46-year old client has just had a femoral-distal bypass. It would be most importnt for the nurse to assess:
C. Pedal pulses
A. Serum cholesterol levels
B. Popliteal pulses
C. Pedal pulses
D. Cardiac enzyme levels
A 33-year old client is having a routine physical examination. The nurse evaluates which of the following data on a urinalysis report as normal?
B. Trace of protein
A. Positive for ketones
B. Trace of protein
C. Positive for glucose
D. Cloudy
A client with chronic renal failure has an arterovenous shunt in the left arm. The nurse makes which of the following assessments of the left arm each shift?
B. Detection of a thrill and bruit.
A. Blood pressure and pulse
B. Detection of a thrill and bruit
C. Venous and arterial distention
D. Skin turgor and skin integrity
A client diagnosed with insulin-dependent diabetes mellitus becomes irritable and confused; the skin is cool and clammy, and the pulse rate is 110. The first action of the nurse would be to
A. Give a half-cup of orange juice.
A. Give a half-cup or orange juice
B. Check the serum glucose
C. Administer regular insulin
D. Call the physician
A client with IDDM is recovering from diabetic ketoacidosis. Information on the serum level of the following substance will be very important to the nurse:
C. Potassium
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
A 17-year old client's mother has recently been diagnosed with pulmonary tuberculosis. The nurse would expect the doctor to order which of the following tests initially?
A. The Mantous
A. The Mantous
B. An x-ray
C. A sputum culture
D. Gram stain of the sputum
The nurse injects 0.1 ml of purified protein derivative (PPD) intradermally into the inner aspect of the raction to this test as positive when the following is seen
C. induration greater than 10 mm
A. Redness greater than 5 mm
B. Swelling greater than 7 mm
C. Induration greater than 10 mm
D. Exudate covering more than 12 mm
A client is receiving whole blood when she starts to shake with chills: her temperature is 101F. The nurse should first:
D. Stop the blood immediately
A. Call the physician immediately
B. Administer the PRN dose of aspirin
C. Start another IV, running normal saline
D. Stop the blood immediately
A 66-year old client with congestive heart failure takes both Digoxin and Lasix daily. The nurse would want to know the results of the following laboratory test:
D. Electrolyte panel
A. Complete blood count
B. Blood urea nitrogen and createnine
C. Coagulation times
D. Electrolyte panel
A 29-year old client has been taking prednisone 60 mg daily for an inflammatory condition for the past 6 months. The physician just wrote an order to discontinue the medication. The nurse should:
C. Call the physician and question the order
A. Stope the medication as ordered
B. Continue the medication until the physician is available
C. Call the physician and question the order.
D. Hold the medication until the physician is available
A 49-year old client with cancer of the lung just had a throacentesis. The nurse would position the client:
C. on the unaffected side
A. On the affected side
B. Sitting
C. On the unaffected side
D. In Fowler's position
A 55-year old client has a chest tube connecgted to a Pleur Evac system to remove blood from the pleural cavity. While turning the client, the nurse remembers to:
A. Keep the Pleur Evac below the level of the wound
A. Keep the Pleur Evac below the level of the wound.
B. Remove the suction from the Pleur Evac.
C. Clamp the tubing connected to the Pleur Evac.
D. Drain the sterile water from the Pleur Evac.
A 26-year old client is having a chest tube inserted into the left upper chest wall posteriorly. The nurse anticipates that which of the following will be used to cover the incision?
D. Sterile petrolatum (Vaseline) gauze
A. Sterile Gauze
B. Kerlix
C. A sterile sealant
D. Sterile petrolatum (Vaseline) gauze
In order to assist women in choosing the appropriate method of contraception, which assessment data should the nurse gather?
A. Current desires about childbearing
A. Current desires about childbearing
B. Nutritional Status
C. Employment history
D. Number of pregnancies
The nurse manager of the family planning clinic instructs the recently hired nurse that part of her duties would include lobbying activities to support federally and state supported family planning services. When asked why this was important, the nurse manager's best response would be:
D. The more services we provide, the more money is saved on unwanted pregnancies.
A. The $ spent on family planning is linked to fewer birth defects.
2. Increasing funding for family planning increases elective abortions.
C. Lobbying will give us publicity and increase our business.
D. The more services we provide, the more money is saved on unwanted pregnancies.
When teaching a client to use the calendar method of contraception, which of the following should the nurse include in her teaching plan?
B.Ovulation occurs around day 14 of the menstrual cycle, sperm are viable up to five days, and ovum live for 24 hours.
A. Ovulation occurs around day 10 of the menstrual cycle, sperm are viable up to 3 days and ovum live for 2 hours.
B. Ovulation occurs around day 14 of the menstrual cycle, sperm are viable up to five days, and ovum live for 24 hours
C. Ovulation occurs around day 18 of the menstrual cycle, sperm are viable up to 2 days, and ovum live for 4 hours
D. Ovulation occurs around day 11 of the menstrual cycle, sperm are viable up to 4 days and ovum live for 48 hours
A client states that her menstrual cycle lasts from 24 - 28 days. The nurse should state that her fertil phase would be:
C.Eighteen days before the end of the shortest cycle through 11 days from the end of the longest
A. 12 days before the end of the shortest cycle through 10 days from the end of the longest.
B. 18 days before the end of the shortest cycle thru 14 days from the end of the longest.
C. 18 days before the end of the shortest cycle thru 11 days from the end of the longest
D. 14 days before the end of the shortest cycle thru 11 days from the end of the longest.
B.
The nurse evaluates a client's correct understanding of ovulation based on the cervical mucu methods when the client states:
d. The mucus will be clear, thin, and stretchable
a. there will bed a lot of thick, white mucus with a strong odor.
b. the mucus will be dark and maybe blood tinged.
c. the mucus will be thick and sticky
d. the mucus will be clear, thin and stretchable
Following a health class on birth control methods, the nurse knows that more teaching is needed when the 16 year old male student states:
a. if I have sex several times in one night, the quantity of my sperm decreases and I'm less likely to get a girl pregnant
a. if I have sex several times in one night, the quantity of my sperm decreases and I'm less likely to get a girl pregnant.
b. The fluid prior to ejactulation may contain some sperm and this could cause a pregnancy.
c. withdrawing prior to ejactulation might not be easy to do.
d. I could still catch a sexually transmitted infection from a girl even if I don't get her pregnant.
Lindy states that she uses douching as a method of birth control. Which of the following statements should the nurse make?
B. Douching may actually facilitate a pregnancy.
a. Douching can be an effective method if used appropriately.
B. Douching may actually facilitate a pregnancy
C. The timing of douching following intercourse is very important.
D. Combining doughing with the use of condoms may assist you in avoiding prenancy and a STI
Callie desires a form of spermicide that she can insert just prior to intercourse. The nurse instructs her to use which of the following?
C. Effervescent spermicides
A. Astroglide
B. KY Jelly
C. Effervescent spermicides
D. Suppositories
The women's health nurse can recommend a barrier method of contraception to which of the following clients?
A. A 37-year old woman who smokes a pack a day
A. 37-year old woman who smokes a pack a day.
b. 16-year old who has no sexual experience
c. 25 year old with a latex allergy
d. 32 year old who has a hx of nonoxynol-9 intolerance
Jackie states that cost is a factor in choosing a birth control method. The nurse offers which of the following options.
C. Diaphragm
A. The female Condom
B. Combined oral contraceptives
C. The diaphragm
D. Vaginal sponge
The community health nurse discusses with a client how her husband makes her feel like a servant. The client states that her husband demands all childcare and housework be done completely by her with no help whatsoever from him. The nurse understands her next assessment questions would explore:
A. Psychological abuse
a. psychological abuse
b. physical abuse
c. sexual abuse
d. sociological abuse
The client describes her male partner's behavior as intimidating and states that she is afraid of him. Which of the following actions would the nurse inquire about?
B. a display of weapons
a. use of religious standards
b. display of weapons
c. forbidding her to see her friends
d. making negative comments about er
The social worker has infomred the community health nurse that a couple with a hx of domestic violence is currently in the tension-building phase of the cycle of violence. The nurse will assess for which of the following during the home visit?
A. the woman is hopeful that her acceptance of blame will diminish the violence
a. the woman is hopeful that her acceptance of blame will diminish the violence
b. the soman states that leaving is not the solution. She has a sprained wrist.
c. the male partner sent flowers and candy. He is loving and sorrowful of his actions.
d. The home is disorderly. There is a large bruise under the woman's right eye and her lip is swollen.
A client admitted to the er for a broken leg confides to the nurse that her boyfriend pushed her down the stairs. The client asks the nurse, "why would he bo so cruel to me?" The nurse's best response would be:
c. men who abuse women are insecure and feel powerless
a. i guess you did something to provoke him and he overreacted.
b. i bet this is a family trend for you. were you battered as a child?
c. men who abuse women are insecure and feel powerless
d. was your boyfriend drinking? alcohol causes domestic violence.
A client comes with multiple bruises on her arms and chest. Her lip is swollen and one of her front teeth is missing. She denies domestic violence and claims falling into fireplace. What is the most appropriate nursing response?
a. the signs are common among women who've been abused. we are trained to assist these women in finding a safe place to escape the abuse.
a. the signs are common among women who've been abused. we are trained to assist these women in finding a safe place to escape the abuse.
b. I know you've been abused. No one is fooled. Why not admit it?
c. I'm sure you did fall into the fireplace. Your injuries are not very life threatening.
d. you'll have no one to blame but yourself if you don't tell us the truth. This will happen again if you return home.
The nurse understands that clarification of knowledge is necessary when a female client who is suspected to have been raped states:
a. just because he made me have oral sex doesn't mean I was raped.
a. just because he made me have oral sex doesn't mean I was raped.
b. I'm going to learn self-defense and fight back next time
c. I thought he was a polite guy who was interested in me. Guess you can't be too careful because a rapist doesn't have any identifying characteristics.
d. I didn't have anything to drink and my clothes were modest, so no one could accuse me of leading him on.
A 12-year old girl, suspected of being raped, is reluctant to provide information regarding her attack. The SANE (sexual assault nurse examiner) addresses which of the following issues first?
b. concerns about confidentiality
a. feelings of guilt
b. concerns about confidentiality
c. fear of retribution
d. lack of knowledge of legal rights
The nurse researcher is gathering data about the types of rape. She is interviewing clients who were recently raped. A 65-year old woman describes her rapist is extremely violent. She states that the rapist continually screamed, "this is what you get" The nurse researcher classifies this type as:
c. anger rape
1. sadistic rape
2. confidence rape
3. anger rape
4. blitz rape
The nurse's teaching plan for a rape prevention class should include which of the following regarding Flunitrazepam (Rohypnol)?
a. ingestion of the drug accelerates intoxication
a. ingestion of the drug accelerates intoxication
b. a white sediment develops in the drink laced with Rohypnol
c. always smell your drinks because adding the drug to a drink creates a citrus aroma.
d. after ingestion, the client may become hyperactive
The nurse working on the sexual assault response team (SART) will begin acquisition of medical and forensic data by first:
c. obtain a detailed hx of the event
a. photograph any physical injuries
b. scrape under the victim's fingernails
c. obtained a detailed hisotry of the event
d. mark clothing and seal in an airtight bag
A nurse is taking a sexual hx from a client in the womens' health clinic. Which of the following statements or questions by the nurse would be most useful in eliciting information concerning the client's risk for sexually transmitted diseases?
a. what types of sexual behaviors are you involved in?
a. what types of sexual behaviors are you involved in?
b. are you happy with your current sex life?
c. women often have concerns or questions about sti's. Do you?
d. I need to write down everything you have to say about your sexual past because this info is very important.
A nurse working in a women's clinic sees four clients with bacterial vaginosis. Which client would be an appropriate candidate for treatment with metronidazole (Flagyl)?
d. 38 year old client in her third trimester of pregnancy
a. 42 year old with a history of pylenonephritis
b. 23 client who is breastfeeding
c. 27 client in her 1st trimester of pregnancy
d. 38 in her 3rd trimester of pregnancy
A client has recurrent episodes of bacterial vaginosis. What further data should the nurse gather?
a. frequency and method of vaginal douching
a frequency and method of vaginal douching
b. hygiene practices
c sexual orientation
d employment history
a client who is being treated with Flagyl for trichomoniasis calls the nurse to report symptoms of abdominal pain, nause, flushing, and tremors. What further data should the nurse gather?
c. alcohol intake
a - last menstrual period
b - complaince of tx regime
c - alcohol intake
4 - pregnancy hx
A sexually active couple present to the women's health clinic. The male partner has been dx'd with candidiasis. The female partner has no symptoms and claims that he has been unfaithful to her. Which of the following nursing statements would be appropriate?
d. Often males are symptomatic while females remain asymptomatic. We will need to test you
a candidiasis always causes a noticeable discharge and pain on intercourse.
b. your partner may have been unfaithful. There's no way to know.
c. candidiasis is not trasmitted sexually. Don't worry about this
Often males are symptomatic while females remain asymptomatic. We will need to test you.
The diabetic pt who deals with frequent episodes of Vulvovaginal Candidiasis asks the nurse if there is anything she can do to help prevent these infections. What would be an appropriate nursing response?
a. choose cotton underwear and avoid douching
a. Choose cotton underwear and avoid douching
b. taking a daily antibiotic may assist you in avoiding this infection
c. wear nylon underwear and douche daily with a scented product
d. avoid sexual intercourse during ovulation
The nurse needs to obtain a clean catch urine specimen from a client who presented to this women's health clinic with symptoms of gonorrhea. What instructions will the nurse give?
a. place a cotton ball into your vagina prior to obtaining the urine specimen
a. place a cotton ball into your vagina prior to obtaining the urine specimen.
b. obtain the 1st stream of urine as the specimen
c. you will have to drink one pint of fluid prior to collection of the specimen
d. the catheter will be removed as soon as I gather the specimen
Which of the following statement from a client receiving treatment for Chlamydia would alert the nurse that further teaching is indicated.
c I will be glad to resume sexual activity now that my treatment has begun
a. I must avoid intercourse for at least 7 days while I'm taking my medication.
b. My partner will need to take the same medicine that I am taking.
c. I will be glad to resume sexual activity now that my treatment has begun
d. If I were pregnant, this infection might cause my baby to develop an eye infection.
A pregnant woman is diagnosed with primary syphilis. Which of the following assessment date would be most important for the nurse to gather?
a allergy to penicillin
a allergy to penicillin
b. previous hx of ti's
c. allergy to metronidazole
d. previous hx of pregnancy
The nurse is discussing the ramifications of the dx of a sti with a young married couple. Which of the following expected outcomes would have priority for this couple?
c. successful coping
a. express positive self-appraisal
b. engage in peer support
c successful coping
d ingest nutrionally adequate diet.
The nurse must choose an appropriate location and method of taking a sexual health history. Which of the following would be the best choise?
b - an interview in the examination room with the door closed
a an interview in the waiting room of the clinic.
b. an interview in the examination room with the door closed.
c. give her a pre-printed history form and ask her partner to assist.
d. mail a pre-printed hx form to her residence
Which of the following statements made by a preteen girl indicates successful adaptation to menarche?
a - my cycle should occur every 28 days and last about five days
a. my cycle should occur every 28 days and last about 5 days.
b. I won't need to wear protection on the last few days of my period.
c. My cycle should occur every 20 days and last about 3 days.
d. super absorbent tampons are the best for teenagers
Carol, age 20 reports to the nurse about her menstrual flow. Which of the following statements made by the client would be cause for further investigaion.
b - I had to change my maxipad at least 14 times today
a - i've saturated one tampon today.
b. I had to change my maxipad at least 14 times today
c. A panty liner is sufficient to maintain my flow
d. I always wear tampons because they are easier to use
Which of the following content areas is important to include in a teaching plan presented to young girls to assist them in preventing toxic shock syndrome?
d - change tampons every three to six hours and wash hands before insertion
a - change pads every 3 - 4 hours and wash hands before application.
b - change pads every one to two hours and wash hands after application
c - change tampons every 6 - 8 hours and wash hands before insertion
d - change tampons every three to six hours and wash hands before insertion
When asked if douching is appropriate, the nurse should respond:
c - douching is associated with susceptibility to infection
a - douching is appropriate during the menstrual cycle only
b - scented douches are associated with relief of vaginal irritation
c - douching is associated with susceptibility to infection
d - douching adds to the cervical mucous plugs and aids in bacteria prevention
Amanda states that her menstrual cycle occurs every 20 days. What additional data should the nurse gather?
a - the amount of flow per cycle
a - the amount of flow per cycle
b - type of protection used
c - age her mother went through menopause
d - number of sexual partners
A 16 year old client states that she has never started her menstrual cycle. The nurse asks about marked weight loss, excessive exercise and prolonged stress. Which cause of amenorrhea is she/he inquiring about?
a - hypothalmic dysfunction
a - hypothalmic dysfunction
b - pituitary dysfunction
c - ovarian failure
d - anatomic abnormalities
A client at the family planning clinic is diagnosed with primary dysmenorrhea. Which of the following should be included in the nurse's teaching plan for non-pharmacological comfort measures?
c - balanced meals and adequate rest
a - initiation of oral contraception.
b - application of cold to the abdomen
c - balanced meals and adequate rest
d - regular emotional counseling
The nurse is taking a neurologic health history from a female client who is concerned with symptoms of premenstrual syndrome. Which of the following symptoms should the nurse inquire about?
b - vertigo
a - urinary retention
b - vertigo
c - edema
d - acne
Marie and her husband are planning pregnancy. She suffers from premenstrual syndrome and asks the nurse which relief measure would be appropriate. The nurse's best response is:
d - increase intake of complex carbohydrates
a - zoloft
b - increase foods containing methylxanthines
c - low dose oral contraceptives
d - increase intake of complex carbohydrates