Kaplan study guide III – Flashcards
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The nurse instructs a pregnant woman with gestational diabetes about her diet. The nurse determines that teaching is effective if the client selects which of the following deserts?
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Cheese and fresh fruit
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The nurse supervises care for a client with a radioactive implant. The nurse should intervene if which of the following is observed?
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The client's mother walks up to the client inside of her room. (client on bedrest while implant in place; visitors should limit time and not stand close or in line with radioactivie source)
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A woman asks the nurse if she can safely drink wine while nursing her baby. Which of the following is the BEST response by the NURSE?
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Alcohol has a CNS depressant effect on the baby.
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Which of the following measures is MOST effective in protecting the nursing staff from harmful exposure to radiation when caring for a patient with a radiation implant?
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Rotate the staff members assigned to the patient.
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The nurse palpates the fundus of a woman after the third stage of labor. The nurse should expect the fundus to be:
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firm and globular
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The nurse observes a staff member palpate uterine contractions. The nurse determines the staff member is using the correct technique if the following is observed?
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Place one hand on the abdomen over the fundus and, with the fingertips, press gently.
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A 28-year-old woman delivers a baby boy. In order to monitor for materal complications, the nurse should be MOST alert to which of the following findings?
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Changes in blood pressure and pulse
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The home care nurse visits a 17-year old who delivered a full-term infant 2 weeks ago. Although the client appears mature, the nurse knows the client's age may interfere with positive mothering because of which of the following?
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The client is still experiencing the dependency of childhood.
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The nurse teaches prenatal classes in the antepartum clinic. Which of the following statements, if made by a client to the nurse, indicates that further teaching is necessary?
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I may feel hot flashes and chills (indicates infection)
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The school nurse attends a soccer game at the local high school. The nurse notes a pregnant woman has grabbed her throat, indicates that she is choking, and is unable to speak. Which of the following actions, if taken by the nurse, is BEST?
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The nurse stands behind the woman and performs chest thrusts.
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A client contacts the nurse and describes some soft and movable masses she felt in her breasts that become enlarged druing menstruation. The nurse should be aware that the client is most likely describing which of the following?
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Fibrocystic disease of the breast (benign cysts-soft, tender & free movin, enlarged during menstraution)
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A fetal heart tracing shows early fetal decelerations. The nurse is aware that this indicates which of the following?
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The FHR slowing early in the contraction, which is an early finding.
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A 20-year-old woman arrives at the hospital in active labor. The client asks the nurse what is the purpose of the fetal monitor. Which of the following responses by the nurse is BEST?
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The purpose of the fetal monitor is to determine if the fetus is receiving adequate amounts of oxygen.
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The nurse performs a home care visit on a mother who delivered a baby three days ago. The client expresses alarm when she hears that her baby has lost 8 oz. Which of the following responses by the nurse is MOST appropriate?
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That is a normal weight loss. Sometimes babies lose as much as 10% of their birth weight.
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The nurse prepares a client for placement of internal radiation. The nurse understands the client will receive an indwelling Foley cathether and a tap water enema for which of the following reasons?
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Prevent displacement of the implant (if bladder or bowel is distended, chance implant will be dislodged increases, cathether helps prevent displacement)
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The nurse instructs a prenatal client about warning signs of pregnancy. The nurse determines teaching is sucessful if the client states which of the following?
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I should contact the physican if I notice swelling in my face and fingers.
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On the evening before a modified radical mastectomy, a 29-year-old patient tells the nurse she is afraid that her husband will not find her sexually attractive if her breast is removed. Which of the following responses by the nurse is BEST?
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You're worried about how he'll react to the changes in your body.
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A multipara woman in her fifth month of pregnancy complains to the nurse that her breasts are sensitive and sore. The nurse should make which of the following suggestions?
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Apply cold compressions and wear a well-fitting supportive bra
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The nurse prepares a client for a cesarean section. The client asks how the anesthesia is going to affect her baby. Which answer given by the nurse is best?
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The amount of narcotic given is decreased in a client undergoing cesarean section.
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The nurse cares for a 6lb, 7 oz baby girl delivered two hours ago. The nurse knows which of the following occurences initiates the changes that take place in the newborn circulatory system after birth?
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The infant begins pulmonary ventilation
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The nurse cares for a client diagnosed with cervical cancer. The nurse notes that the client appears to have a poor appetite. Which of the following interventions by the nurse is BEST?
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Provide small, frequent feedings.
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The nurse cares for a patient 24 hours after deliver, and the patient states that she has been voiding large amounts of urine. Which of the following responses by the nurse is BEST?
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Your body is getting rid of the increased fluid (diaphoresis occuring)
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A nurse teaches a client about birth control methods. How long should the nurse advise the client to leave a diaphragm in place after intercourse?
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6 hours
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Meconium-stained amniotic fluid should alert the nurse to the possibility of which?
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Fetal distress and perinatal asphyxia
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The nurse intructs a group of expectant mothers about the advantages of breastfeeding. The nurse should intervene if an expectant mother makes which of the following statements?
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My baby will grow faster and sleep more with breast milk.
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After a newborn circumcision, the nurse should take which of the following actions?
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Apply petroleum gauze and observe carefully for bleeding.
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The parents of a a preterm infant visit the infant in the newborn nursery. They see their infant resting comfortably in the isolette and express concern about disturbing the baby. Which of the following reponses by the nurse is BEST?
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Preterm infants need to develop a sense of trust and security and holding the infant promotes this.
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The nurse knows that a low-birth-weight infant is at greatest risk for developing which of the following?
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Respiratory distress syndrome.
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A nurse counsels a couple who have had difficulty conceiving a child. The nurse explains infertility is defined as which of the following?
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Inability to conceive after at least one year of unprotected intercourse.
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The nurse cares for a patient receiving magnesium sulfate IV, and the nurse notes that the patient's deep tendon reflexes are decreased. Which of the following actions should the nurse take FIRST?
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Discontinue the IV infusion.
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A woman tells the nurse that she has always had a heavy menstaul flow and needs extra iron. The nurse should recommend the client should eat which of the following foods?
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Chicken livers
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The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's blood pressure is 150/96, edema of the face and hands is noted, 3+ protein in the urine, and serum albumin level is 3 gm/dL. Which if the following instructions by the nurse is MOST important?
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The client should ensure adequate protein.
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The nurse notes that a two-day-old infant shows a tendency to bleed. The nurse understands this is MOST likely caused by which of the following?
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Absence of intestinal bacteria needed for the production of vitamin K.
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The nurse prepates a client for abdominal hysterectomy. The client asks why she has to have a Foley catheter. Which of the following statements by the nurse is most appropriate?
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This will allow you to heal by keeping your bladder decompressed.
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The physican orders a coloscopy. The nurse explains to the client that the purpose of the colonoscopy is to
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magnify the tissue for examination
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When administering photherapy to a newborn with jaundice, it is MOST important for the nurse to take which of the following actions?
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Cover the infant's eyes with protective pads during therapy.
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The nurse admits a patient to the postpartum unit two hours after vaginal delivery. Three hours after admission the nurse ambulates the patient to the bathroom, and the patient states there is a sudden gush of bleeding from her vagina. The nurse understands that the increase in amount of bleeding is due to which of the following?
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THe lochla pooled in the patient's vagina when she was lying in bed.
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By her fifth month of pregnancy, a 32-year old multipara of average prenatal height and weight has gained 14 pounds. Which of the following actions by the nurse is MOST important?
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Inform the client her weight gain is appropriate and she should continue on her present diet.
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A woman complains to the nurse that during the client's menstraul period she gains weight and gets muscle cramps. The nurse should suggest which of the following measures to alleviate the client's symtoms?
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Take over-the-counter analgesics, restrict caffeine, exercise moderately.
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The nurse care for a woman in labor. Which method should the nurse use to measure the frequency of uterine contraction?
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Timing the contraction from the beginnning of one contraction to the beginning of the next contraction.
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The nurse cares for a patient after a breast biopsy. After the procedure, it is MOST important for the nurse to take which of the following actions?
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Observe for bleeding.
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The nurse observes four newborns. Which of the following characteristics, if noted by the nurse, are MOST common in preterm infant?
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Red, wrinkled skin, lanugo, and hypotonic muscles.
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The nurse instructs a client in the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client selects which of the following foods from a menu?
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Two eggs and 8 oz of milk.
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A 25-year-old primigravida diagnosed with type 1 diabetes mellitus reviews insulin regimen with the nurse. THe nurse reinforces the importance of regular prenatal care and explains changes in insulin requirements will include which of the following?
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Insulin requirements will increase during pregnancy and decrease after delivery.
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A woman is in active labor. As labor progresses, she bevomes irritable and complains of feeling increasingly uncomfortable. She is 8 cm dilated. Which of these actions should the nurse take FIRST?
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Coach the patient in proper breathing and relaxtion techniques.
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The nurse cares for a patient in labor. The patient suddenly shouts, "I have to push! I have to push!" The nurse determines that the patient is 8 cm dilated. Which of the following actions should the nurse take first?
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Encourage the patient to pant with pursed lips.
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The nurse instructs a patient who recently had a modified radical mastectomy. The nurse states that it is important that the patient exercise her arm postoperatively to
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prevent lymphedema
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THe nurse prepares a client for a total abdominal hysterectomy with bilateral salpingo-oophorectomy due to uterine cancer. The nurse observes that the client is client is talking continously and has difficulty maintaining eye contact. Which of the following responses by the nurse is BEST?
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What are your concerns about the surgery?
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A nurse accidentially bumps into a newborn's bassient. The newborn jumps and pulls the extremities into the trunk. The nurse identifies he newborn is demonstrating which of the following reflexes?
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Moro's
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Babinski's
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stroking sole of foot from heel upward across ball of foot cauing toes to fan
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Rooting
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Turns toward any object touching/stroking cheek/mouth
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An infant is born by vaginal delivery. At birth, the infant is crying & respiration & pulse rate are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At five minutes after birth, the extremities are pink. The nurse should record baby's one-minute & five-minute Apgar scores as which of the following?
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9 & 10, respectively
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To assess an apical pulse on a 8 lb, 4 oz newborn infant, the nurse should take which of the following actions?
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Place the bell of the stethoscope between the fourth & fifth intercostal spaces, the midclavicular line.
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A woman is in active labor when her membranes rupture. She expresses a concern to the nurse she is afraid of having a "dry labor." Which of the following responses by the nurse is MOST appropriate?
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Amnoitic fluid does not function as a lubrication for the labor process.
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The nurse should place the HIGHEST proirity on monitoring a woman after a cesarean section for which of the following?
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Hemorrhage & shock
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A woman comes to the clinic pregnant with her second child. She qustions the nurse about the amount of exercise that is acceptable for her to perform during her pregnancy. Which of the following is the MOST important response by the nurse?
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What is your usual type of exercise?
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The nurse monitors a client at 30 weeks gestation, and the client states that she has periodic heartburn. It is MOST important for the nurse to make which of the following recommendations?
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Eat frequent and small meals.
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The nurse cares for clients in the prenatal clinic. The nurse identifies which of the following pregnant women as MOST likely to have a problem with Rh incompatibility with her fetus?
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An Rh-negative woman who conceived with a Rh-positive man and who has Rh antibodies
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The nurse instructs a woman about how to prevent conception using the basal body temperature (BBT) method. The nurse explains that during ovulation, a woman's basal body temperature
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rises slightly
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A client comes to the prenatal clinic for her first visit. THe nursing history reveals that the client's last menstraul period was five months ago, and the client is sure she is pregnant becaue she has been feeling the baby move. Which of the following responses by the nurse is BEST?
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Lie down so that I can listen for fetal heart tones with the Doppler.
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The nurse cares for a patient immediately after a normal vaginal delivery. WHich of the following actions should the nurse take FIRST?
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Check the lochial flow
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A woman arrives at the hospital in labor. THe midwife states that the client is 4 cm dilated and 60% effaced. The nurse explains to the client this means which of the following?
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The opening of the cervix is 4 cm wide and the cervical canal is 60% shorter than normal.
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The nurse cares for a patient 12 hours after delivery of a 3,200 g infant. The nurse notes that the fundus is approximately 1 cm above the umbilicus. It is MOST important for the nurse to take which of the following actions?
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Chart the results in the patient's chart.
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In he delivery room, the nurse places drops in the newborn's eyes. The nurse explains to the mother the drops
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protect against infections that could lead to blindness
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A patient is admitted to the hospital and is scheduled to have a modified radical mastectomy. The patient asks the nurse about the surgical procedure. Which of the following explanations should the nurse give?
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The breast, axillary nodes, and superior apical nodes are removed but the muscles are preserved.
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The nurse is caring for a patient in labor. The patient's labor progresses with regular contractions until her cervix is 9 cm dilated. The nurse identifies the patient in which stage of labor?
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First stage.
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The nurse assesses a client in the family planning clinic. Which of the following statements, if made by a client, suggests to the nurse that the client has been exposed to gonorrhea?
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My boyfriend has a drip
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A woman at 29 weeks gestation comes to the emergency room complaining of vaginal bleeding. The nurse identifies which of the following patient statements as indicative of a placenta previa?
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The bleeding scares me, other than that I feel fine.
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A woman has a simple vulvectomy. Postoperatively, the nurse instructs her to take a sitz bath and keep the area clean and dry. The nurse understands the reason for these measures is
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to increase circulation to the area and promote wound healing
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The nurse observes the interactions of mother and infant born three hours ago. The mother had gestational diabetes and delivered by cesarean section at 37 weeks gestation. The infants Apgar scores were 6 and 8, birth weight 10 obs, heart rate 122 bpm, and respirations 35/min. The mother tells the nurse, "I don't know why my physican was worried about my baby. She looks so big and healthy!" Which response by the nurse is BEST?
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The baby's large size is due to the amount of sugar that she received in utero.
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The nurse leads a prenatal class about breastfeeding. Which of the following statements, if made by the nurse, accurately describes the nutritional needs of a woman during lactation as compared to the nutritional needs of pregnancy?
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More calories but the same amount of protein, calcium, and fluids are needed.
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The nurse cares for a 4 lb, 10 oz infant delivered at 32 weeks gestation. The nurse notes that the infant has mottling of the skin, and lab values indicate metabolic and respiratory acidosis. The nurse recognizes these findings are signs of which of the following?
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Cold Stress
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The nurse cares for a patient in labor. The nurse notes that the patient appears more peaceful and there is an increase in bloody show. The nurse identifies the patient is in which stage of labor?
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Second stage
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The nurse prepares a client for a gynecological examination. The nurse explains that the physician will perform a pelvic examination and will obtain a Pap smear. The nurse explains the Pap smear is
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a speciman of cells used to identify abnormal cells
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During auscultation of the fetal heart rate (FHR) during labor. The nurse assesses a rate of 59 beats/min. Which actions should the nurse take FIRST?
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Turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
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The nurse cares for a newborn delivered by a mother addicted to nacortics. During which of the following times is the nurse MOST likely observe symptoms of narcotic withdrawal?
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Within 24-72 hours after birth.
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A 32-year-old woman is pregnant for the third time. She has one living child and has had one abortion. Which description does the nurse record?
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Gravidida III, para I. (Para I is when the fetus reaches age of vitality- once; gravidida III means 3 pregnancies)
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A young mother delivers a healthy 7 lb 12 oz boy. She confides to the nurse that she is concerned about the two "soft spots" she found on her baby's head. The nurse's response should be based on which of the following?
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The baby's anterior fontanel should close after about a year and a half.
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A coupld comes to the fertility clinic after trying for several years to have children. The woman has a regular 28-day menstraul cycle. The nurse explains to her she is MOST likely to become pregnant
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10-14 days after the onset of her menstraul period.
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The nurse cares for a client immediately after delivery and admisters oxycocin. The nurse knows that the purpose of this medication is to
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stimulate the contraction of the uterus
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During labor induction with oxytocin, the nurse should stop the infusion if which of the following occurs?
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Contractions are at 2-min intervals and last more than 90 seconds
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The nurse explains to a client at 6 weeks gestation which of the following periods of pregnancy is the most critical time for fetal development?
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The first three months
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The nurse instructs a new mother about how to care for her newborn's umbilical cord. The nurse determines teaching is effective if the client makes which statement?
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I will clean the cord and skin around it with water. I will contact my physician if there is white or yellow discharge from the cord.
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The nurse understands that the physican is most likely to prescribe which of the following drugs to a client diagnosed with gonorrhea?
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Cefriaxone IM plus doxycycline for seven days by mouth
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A woman comes to the hospital in labor. Her membranes rupture at 4:10 a.m. Which of the following actions should the nurse take FIRST?
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Observe for a prolapsed cord or meconium-stained fluid.
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The nurse instructs a group of expectant mothers about how to recognize the onset of labor. The nurse knows that further teaching is necessary if a client makes which statement?
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My baby will move more when I go into labor.
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The nurse counsels clients in the prenatal clinic. The nurse is MOST concerned if the cleint makes which statement?
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I clean the cat's litter box daily.
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The nurse teaches a class about gonorrhea. Which of the following statements, if made by the client, indicates that teaching is successful?
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I've heard that having gonorrhea can make you unable to have children.
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The nurse cares for the client six hours after a vaginal delivery and assists the client to perform perineal care. Fifteen minutes later, the nurse notes that the perineal pad is soaked and there is blood underneath the client's buttocks. Which action should the nurse perform first?
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Notify the Health care provider.
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The home care nurse makes a home visit to a client diagnosed with type 1 diabetes at 29 weeks gestation. The client states that she has been nauseated for 24 hours. It is MOST important for the nurse to ask which of the following questions?
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Have you taken your insulin today?
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The nurse performs a home visit on a new mother and her two-week-old son. The mother is breastfeeding. She tells the nurse that the baby nurses 8-9 times per day, has regained all of the lost birth weight, has 6-8 wet diapers per day, and usually has one bowel movement per day. Which of the following responses by the nurse is BEST?
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Your baby is doing great.
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The nurse cares for a woman in labor. The nurse is MOST concerned the fetus is experiencing distress if which is observed?
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Late decelerations.
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The nurse cares for a patient right after a right below-the-knee amputation. The nurse is MOST concerned if which of the following is observed?
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The patient complains of persistent pain at the operative site.
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The clinic nurse counsels a client complaining of low back pain. Which of the following statements, if made by the client to the nurse, requires a follow-up by the nurse?
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I work full-time as a checker at the local grocery store.
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The nurse in the outpatient clinic is measuring the height of an older woman. The client expresses suprise that she is 1 inch shorter than she used to be. Which of the following statements by the nurse is BEST?
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You are shorter as a resulst of Paget's disease. (bowing of legs common with Paget's disease)
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The nurse performs a home care visit on a client with a fractured right femur. The nurse assesses the client's safety when using crutches. The nurse should intervene if which of the following is observed?
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Before sitting in a chair, client stands on the unaffected leg and transfers both crutches in the hand opposite the unaffected leg
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A patient diagnosed with type 1 diabetes is scheduled for right below-the-knee amputation due to a gangrenous toe. The patient asks the nurse why the amputation is so extensive. The nurse's response should be based on which of the following?
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A below-the-knee amputation results in better circulation and healing.
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The nurse performs discharge teaching for a patient diagnosed with a fractured left femur that is in a cast. The patient asks how to keep the muscles of the leg strong during the time the cast is on the left leg. Which response by the nurse is BEST?
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I'll teach you how to do isometric exercises.
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The nurse cares for a client with an amputation with an immediate prosthetic fitting. The nurse should include which of the following in the client's plan of care?
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Provide cast care on the affected extremity.
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The nurse cares for a patient after a total hip replacement due to degenerate joint disease. The nurse should intervene if which of the following is observed?
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The patient's heels are lying on the bed with toes pointed upward.
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Prednisone 2 mg qd is prescribed for a patient with rheumatoid arthritis. What important points should the nurse include when teaching the patient about this drug?
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The dosage of prednisone must be increased and decreased gradually.
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A client is evaluated in the clinic for rheumatoid arthritis. Which of the following findings should assume the highest priority for the nurse when assessing and planning the client's care?
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Slight contracture of the right wrist.
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A nurse returns to the car after grocery shopping and witnesses a car hit a pedestrian in the parking lot. As the nurse approaches the pedestrian, the pedestrian cries out, "I think my leg is broken!" Which of the following actions should the nurse take FIRST?
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Cut away the cleint's pant leg on the affected side.
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The nure evaluates care given to a patient after a left below-the-knee amputation. The nurse should intervene if which of the following is observed?
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A tourniquet is placed in the patient's bedside table.
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A nurse is caring for an elderly patient diagnosed with a fractured femur. The nurse recognizes that which of the following may be an early sign of fat embolism?
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Altered mental status
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Salicylic acid (asprin) is prescribed for a patient. The nurse should admister this medication with which of the following?
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A glass of milk. (or with food-to reduce GI upset)
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The home are nurse makes a home visit for a client diagnosed with osteoarthritis. The nurse asks the client's spouse if the client is having any problems. The nurse should further assess if the spouse makes which statement?
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I can tell that my husband has been worrying because he has been wringing his hands.
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A nurse cares for a patient in Buck's traction. It is MOST important for the nurse to take which of the following actions?
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Allow weights to hang freely at all times.
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The nurse is caring for a patient with degenerative joint disease (osteoarthritis). The physician orders celecoxib (Celebrex). The nurse is MOST concerned if the patient makes which of the following statments?
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I am allergic to aspirin.
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The nurse assesses a patient with a diagnosis of osteoarthrisis. The nurse expects to observe which of the following signs/symptoms?
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Stiffness of the hips, knees, vertebrate, and fingers.
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An elderly female patient undergoes an open reduction an internal fixation of the left femoral head after fracture. Which action by the nurse is BEST?
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Encourage the patient to cough and deep breathe q 2 hours.
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The nurse cares for an elderly patient eight days after an open reduction and internal fixation of the right hip. The nurse should intervene if which is observed?
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The patient is not weaing elastic stockings.
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The nurse prepares a patient for a total hip replacement. Which of the following observations by the nurse necessitates contracting the physician?
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The patient complains of burning on urination.
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During an acute bout of gouty arthritis, the nurse should expect the patient's affected foot to appear
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red
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Total hip arthroplasty is scheduled for a patient with degenerative joint disease of the left femoral head. It is MOST important for the nurse to place the patient's left leg in which of the following positios?
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Abducted with toes pointing upward
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The nurse cares for a client with newly applied plastic cast to the lower extremity. The nurse should take which action?
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Elevate the leg on pillows and leave the cast open to air.
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The nurse in the outpatient clinic is intructing a client receiving probenecid (Benemid). It is MOST important for the nurse to make which of the following statements?
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Drink 6-8 glasses of water each day.
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A patient asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which of the the following responses by the nurse is BEST?
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Rheumatoid arthritis is a systemic disease and osteoarthritis is not.
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Three hours after arriving at the orthopedic unit, a patient complains about a hot feeling under the cast. Which action should the nurse take FIRST?
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Check the circulation in the casted extremity and change the patient's position.
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In teaching a patient wiht a below-the-knee amputation to care for the residual limb at home, the nurse should advise the pateint to do which of the following?
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Expose the residual limb to air.
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Which of the following nursing interventions is MOST appropriate for a patient diagnosed with rheumatoid arthritis?
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Assist the patient with heat application and range-of-motion exercises.
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The nurse cares for a patient in balanced suspension traction. The patient complains of pain in the affected extremity, and the nurse administers the prescribed medication. One hour later, the patient states, "I don't know why, but the pain isn't getting any better." Which of the following actions should the nurse take FIRST?
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Perform a neurovascular assessment.
