The nurse is caring for a client during the fourth stage of labor. Which of the following nursing interventions would be LEAST appropriate?

• A. Catheterization to protect the bladder from trauma. 
• B. Perineal assessments for swelling and bleeding. 
• C. Vital signs and fundal checks every 15 minutes. 
• D. Time with the neonate to initiate breast-feeding.

The nurse is providing home care to a client with failing vision due to macular degeneration. The nurse is concerned about the client's safety. Which of the following activities would help to lessen the client's risk of falling?

• A. Arranging pieces of furniture close together so the client can use them for guidance and support. 
• B. Encouraging the client to wear a medical identification bracelet that describes the client's visual deficit. 
• C. Installing a flashing light to indicate when the phone or doorbell is ringing. 
• D. Installing handrails in hallways, in bathrooms, and on steps.

Mrs. S with preterm labor will be under Terbutaline (Brethine) therapy. Before beginning the therapy, which of the following assessments would be most important?

• A. Estimated fetal size. 
• B. Maternal heart rate. 
• C. Contraction intensity. 
• D. Deep tendon reflexes.

Which of the following should be the nurse's initial action immediately following the birth of the neonate?

• A. Aspirating mucus from the neonate's nose and mouth. 
• B. Drying the infant to stabilize the neonate's temperature. 
• C. Promoting parental bonding. 
• D. Identifying the neonate.

A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost?

• A. 1 pound. 
• B. 3 pounds. 
• C. 5 pounds. 
• D. 7 pounds.

Which of the following describes a preterm neonate?

• A. A neonate weighing less than 2,500 g (5 lb, 8 oz).
• B. A low-birth-weight neonate.
• C. A neonate born at less than 37 weeks' gestation regardless of weight.
• D. A neonate diagnosed with intrauterine growth retardation.

The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury?

• A. Bend over the object you're lifting. 
• B. Narrow the stance when lifting. 
• C. Push or puI1 an object using your arms. 
• D. Stand close to the object you're lifting.

A client asks the nurse what PSA is. The nurse should reply that it stands for

• A. prostate-specific antigen, used to screen for prostate cancer. 
• B. protein serum antigen, used to determine protein levels. 
• C. pneumococcal strep antigen, a bacteria that causes pneumonia. 
• D. papanicolaou-specific antigen, used to screen for cervical cancer.

The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?

• A. Poor clotting mechanism. 
• B. High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood. 
• C. Persistent fetal circulation. 
• D. Large, immature liver.

For a client in addisonian crisis, it would be very risky for a nurse to administer

• A. potassium chloride. 
• B. normal saline solution. 
• C. hydrocortisone. 
• D. fludrocortisone.

A client with cholecystitis is receiving propantheline bromide. The client is given this medication because it

• A. reduces gastric solution production and hypermobility. 
• B. slows emptying of the stomach and reduces chyme in the duodenum. 
• C. inhibits contraction of the bile duct and gallbladder. 
• D. decreases bile secretions.

In an industrial accident, a client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?

• A. A urine output consistently above 100 mL/hr. 
• B. A weight gain of 4 lb (1.8 kg) in 24 hours. 
• C. Body temperature readings all within normal limits. 
• D. An electrocardiogram (ECG) showing no arrhythmias.

A client who has a potassium level of 6 mEq/L should be treated with

• A. antacids. 
• B. IV fluids. 
• C. fluid restriction. 
• D. sodium polystyrene sulfonate (Kayexalate).

A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is LEAST likely to be included in her plan of care?

• A. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes. 
• B. Allowing the client to ambulate as tolerated. 
• C. Helping the client use breathing exercises to manage her contractions. 
• D. Carefully titrating the oxytocin based on her pattern of labor.

Which of the following is an early sign of laryngeal cancer?

• A. Difficulty swallowing. 
• B. Chronic foul breath. 
• C. Persistent mild hoarseness. 
• D. Nagging unproductive cough.

The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using

• A. antiembolism stockings.
• B. oxygen. 
• C. diuretics. 
• D. anticoagulants.

Which of the following statements about external otitis is true?

• A. External otitis is eharaeterized by pain when the pinna of the ear is pulled. 
• B. External otitis is usually accompanied by a high fever in children. 
• C. External otitis is usually related to an upper respiratory infection. 
• D. External otitis can be prevented by using cotton-tipped applicators to clean the ear.

After 5 days of hospitalization, the client who is receiving morphine sulfate for pain control asks for more pain medication with increasing frequency and exhibits increased anxiety and restlessness. His physical condition is stable. What is the probable cause of his behavior?

• A. His morphine dosage is too high. 
• B. His coping mechanisms are exhausted. 
• C. He is becoming addicted to the narcotic. 
• D. He has developed tolerance to his narcotic dosage.

As part of the annual health screening, the nurse visits the eighth-grade physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing?

• A. Slipped epiphysis. 
• B. Developmental dysplasia of hip. 
• C. Idiopathic scoliosis. 
• D. Physical dexterity.

Nursing care for a client after electroeonvulsive therapy (ECT) should include which of the following?

• A. Nothing by mouth for 24 hours after the treatment because of the anesthetic agent. 
• B. Bed rest for the first 8 hours after a treatment. 
• C. Assessment of short-term memory loss. 
• D. No special care.

The nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Which medication would be used to treat his bradycardia?

• A. Atropine. 
• B. Dobutamine (Dobutrex). 
• C. Bretylium (Bretylol). 
• D. Lidocaine (Xylocaine).

A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress?

• A. Intercostal retractions.
• B. Bradycardia.
• C. Decreased level of consciousness.
• D. Flushed skin.

Which of the following home regimens should the nurse suggest to relieve itching in children with chicken pox?

• A. Generous amounts of fine baby powder. 
• B. Oatmeal preparation baths. 
• C. Terrycloth towels moistened with hydrogen peroxide. 
• D. Cool compresses moistened with a weak salt solution.

A 16-year-old student has been admitted to your psychiatric unit after fainting in physical education class. She has a diagnosis of anorexia nervosa, weighs 88 lb (40 kg), and is 5'4" (1.6 m) tall. She has been weighing herself several times per day at home and has lost 30 lb (13.5 kg) in the past 3 months. Which nursing diagnosis would be most appropriate for the client?

• A. Disturbed thought processes. 
• B. Impaired adjustment. 
• C. Imbalanced nutrition. Less than body requirements. 
• D. Ineffective sexuality patterns.

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to have which of the following findings?

• A. Tension and irritability. 
• B. Slow pulse. 
• C. Hypotension. 
• D. Constipation.

When completing an assessment of a healthy adolescent client, which of the following would be most appropriate?

• A. Obtain a detailed account of the adolescent's prenatal and early developmental history. 
• B. Discuss sexual preferences and behaviors with the parents present for legal reasons. 
• C. Discuss the client's smoking with parents present in the room. 
• D. Assess the adolescent in private; gather additional information from the parents.

When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, the nurse should know the correct hemoglobin (Hb) values
  for children. Which of the following ranges would be inaccurate?

• A. Neonates. 10.6 to 16.5. 
• B. 3 months. 10.6 to 16.5. 
• C. 3 years. 9.4 to 15.5. 
• D. 10 years. 10.7 to 15.5.

When assessing a toddler diagnosed with spastic cerebral palsy, which of the following would the nurse expect to find?

• A. Toe-walking. 
• B. Drooling. 
• C. Facial grimacing. 
• D. Wide-based gait.

Which of the following would be an appropriate expected outcome of nursing care for the client with ulcerative colitis?

• A. The client experiences decreased frequency of constipation. 
• B. The client accepts that an ileostomy will be necessary. 
• C. The client maintains an ideal body weight. 
• D. The client verbalizes the importance of restricting fluids.

A female neonate delivered by elective cesarean birth to a 25-year-old mother weighs 3,265g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following?

• A. Temperature instability due to type of birth. 
• B. Respiratory distress due to lack of contractions. 
• C. Signs of acrocyanosis. 
• D. Unstable blood sugars.

A young adult had a significant reaction to the Mantoux test. What conclusion would the nurse make from the findings?

• A. The client has active tuberculosis. 
• B. The client had active tuberculosis. 
• C. The client has been exposed to tuberculosis. 
• D. The client is immunocompromised.

A child with type 1 diabetes mellitus develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk for this child?

• A. Hypercalcemia. 
• B. Hyperphosphatemia. 
• C. Hypokalemia. 
• D. Hypernatremia.

A few days after a colectomy, a client suddenly develops chest pain, shortness of breath, and air hunger. The nurse knows she must further assess the client's chest pain to determine its origin. When determining whether the chest pain is cardiac or pleuritic in nature, the nurse knows that pleuritic chest pain typically

• A. is described as crushing and substernal. 
• B. worsens with deep inspiration. 
• C. is relieved with nitroglycerin. 
• D. is relieved when the client leans forward.

The clinic nurse is instructing a group of parents about emergency treatment for accidental poisoning and injury. Which of the following statements by one of the mothers indicates that she needs further instruction?

• A. "I should flush my child's eye with room temperature tap water for 15 to 20 minutes if a caustic material gets into it. " 
• B. "I should save the emesis if my child vomits. " 
• C. "I should call the poison control center if there are any symptoms. " 
• D. "I should give 2 to 5 teaspoons of clear fluids after administering ipecac. "

A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses adequate understanding of nutritional needs during pregnancy?

• A. "I expect to gain a few pounds each month at first. Then I'll really get big and put on 20 pounds or so. " 
• B. "I guess I will get big and gain 20 to 30 pounds and look pregnant." 
• C. "Because I have to eat for two, I should eat whatever I want whenever I feel hungry. " 
• D. "I will need to eat more so that I will gain about 25 pounds, but I want to make sure I don't fill up with junk food. "

The immobile adolescent with a recent fractured femur suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia. Which of the following would the nurse suspect?

• A. Atelectasis. 
• B. Pneumonia. 
• C. Pulmonary edema. 
• D. Pulmonary emboli.

A 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprung's disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention takes priority?

• A. Changing the surgical dressing. 
• B. Suctioning the nasopharynx frequently to remove secretions. 
• C. Irrigating the colostomy with 100 ml of normal saline solution. 
• D. Auscultating lung sounds.

Which of the following functions would the nurse expect to be unrelated to the placenta?

• A. Production of estrogen and progesterone. 
• B. Detoxification of some drugs and chemicals. 
• C. Exchange site for food, gases, and waste. 
• D. Production of maternal antibodies.

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?

• A. "The cast will be removed in 6 weeks. " 
• B. "A new cast is needed every 1 to 2 weeks. " 
• C. "A short leg cast is applied when the baby is ready to walk. " 
• D. "The cast will be removed when the baby begins to crawl. "

The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP) ?

• A. Suction the airway every hour and as needed. 
• B. Elevate the head of the bed 15 to 30 degrees. 
• C. Turn the client and change his position every 2 hours. 
• D. Maintain a well-lit room.

The nurse is making a plan of care for the child with juvenile rheumatoid arthritis to reduce joint pain in the morning just after arising. Which of the following interventions would be included in the plan?

• A. Awakening the child once nightly to exercise the joints. 
• B. Having the child sleep in a sleeping bag. 
• C. Having the child sleep with the joints flexed. 
• D. Increasing pain medication at bedtime.

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions?

• A. Hyperpyrexia, slow pulse, and weight gain. 
• B. Tachycardia, weight loss, and mood swings. 
• C. Hypotension, weight gain, and listlessness. 
• D. Increased appetite, slowing of sensorium, and arrhythmias.

An elderly client's lithium level is 1.4 mEq/L. She complains of diarrhea, tremors, and nausea. The nurse's first action is to

• A. hold the lithium (Lithobid) and notify the physician. 
• B. reassure the client that these are normal adverse effects. 
• C. administer another lithium dose. 
• D. discontinue the lithium.

Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience

• A. heat intolerance and systolic hypertension. 
• B. weight gain and heat intolerance. 
• C. diastolic hypertension and widened pulse pressure. 
• D. anorexia and hyperexcitability.

When developing a plan of home care for the client with multiple sclerosis, the nurse should teach the client about which of the following complications most likely to occur?

• A. Ascites. 
• B. Contractures. 
• C. Fluid volume overload. 
• D. Myocardial infarction.

A registered nurse who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short staffed and needs additional help to care for the clients. The nurse has never worked in the CCU. Which of the following responses is the most appropriate nursing action?

• A. Call the hospital lawyer. 
• B. Report to the CCU and identify tasks that she feels she can safely perform. 
• C. Speak to the nursing supervisor. 
• D. Refuse to go to the CCU.

After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs'test. What's the purpose of performing this test on a pregnant client?

• A. To determine the fetal blood Rh factor. 
• B. To determine the maternal blood Rh factor. 
• C. To detect maternal antibodies against fetal Rh-positive factor. 
• D. To detect maternal antibodies against fetal Rh-negative factor.

Which pregnancy-related physiologic change would place the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems?

• A. Decreased heart rate. 
• B. Decreased cardiac output. 
• C. Increased plasma volume. 
• D. Increased blood pressure.

While assessing a client who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects

• A. a urinary tract infection. 
• B. renal calculi. 
• C. an enlarged kidney. 
• D. a distended bladder.

A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that

• A. these students are too young to screen; instead, older students should be screened. 
• B. these students are too old to screen and will no longer benefit from screening for scoliosis. 
• C. scoliosis screening requires sophisticated equipment and can't be done in school. 
• D. this is an appropriate request and arrangements will be made as soon as possible.