RN Concept Level 3 Practice A
A nurse is providing family education for a client who wishes to conceive...the nurse should identify that
ovulation is expected to occur on which of the following calendar dates? - ANS D-the 19th.- The nurse
should teach the client that ovulation is expected to occur 13-15 days after day one of her menses.
Ovulation signals the beginning of the secretory phase of the endometrial cycle. Knowing when
ovulation is expected to occur helps the client identify periods of fertility to increase her chances of
conception.
A nurse in an acute care mental health facility is planning care for a client who has bipolar disorder and
who is experiencing acute mania. What action should the nurse take?
- encourage client to take part in daily group meetings (no, they should have one-to-one activities)
-allow client to pick from a variety of activities on the unit (no nurse should provide scheduled meals &
rest periods)
- assign the client to a semiprivate room (no, reduce stimuli and assign to a PRIVATE room w reduced
noise/lighting)
- provide client w finger foods(YES, pts experiencing mania are often unable to sit and eat, finger foods
allow them to get up and move around - ANS Provide the client with finger foods to eat.
(pts experiencing mania are often unable to sit and eat * can become dehydrated & lose weight, finger
foods (sandwiches) allow pt to eat while standing/walking & obtain nutrition even though she cannot sit
down for a meal)
A nurse is caring for an infant who has Tetralogy of Fallot. The nurse notes that the infant exhibits a
sudden onset of cyanosis and is hyperpneic. What action should the nurse take? - ANS Place the infant in
a knee-chest position.
,-This maximizes the oxygenation status of the infant during hyper-cyanotic episodes
-The nurse should administer 100% oxygen via facemask to the infant during hypercyanotic episodes.
-The nurse should administer morphine subcutaneously or through an existing IV line during
hypercyanotic episodes.
-The nurse should initiate or increase the rate of IV fluids to the infant during hypercyanotic episodes.
A nurse is providing discharge teaching to a client following gastric bypass surgery for management of
obesity. What is a client statement that indicates understanding of the teaching? - ANS "I will remain in a
reclining position for 30 minutes after I eat"
Following gastric bypass surgery, clients are at risk for dumping syndrome. Remaining in a reclining
position slows gastric emptying and minimizes the risk of dumping syndrome.
R/T Gastric bypass surgery - ANS -The nurse should teach the client that the area between skin folds
should be kept clean and dry. Applying a moisturizing lotion can cause breakdown of the skin.
-The nurse should teach the client that his diet will consist of pureed foods and liquids for a minimum of
6 weeks following surgery. After this period of time, the client can gradually return to a solid diet.
-The nurse should teach the client that gastric bypass surgery results in a loss of intrinsic factor, which is
a protein secreted by the stomach that is necessary for absorption of vitamin B12, and therefore
requires monthly injections of vitamin B12 and iron. Digestive enzymes are not required.
A nurse is teaching a client who has genital herpes simplex virus. What statement should the nurse
include in the teaching about this STI? - ANS "You should cleanse the lesions with a saline solution twice
each day."
The nurse should teach the client to cleanse the lesions twice each day with a saline solution to prevent
secondary bacterial infections.
R/T Genital herpes simplex virus - ANS -The nurse should teach the client to take over-the-counter
analgesics such as acetaminophen, ibuprofen, or aspirin to control pain associated with the infection.
,-The nurse should teach the client that there is no cure for genital herpes. As a courtesy, the client
should contact all sexual partners so they can receive treatment; however, the law does not require
prior sexual partners to be contacted.
-The nurse should teach the client that there is no cure for genital herpes. Antiviral medication like
acyclovir can reduce the symptoms during active infections.
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following
actions should the nurse take? - ANS Apply a thin coating of lip balm to the client's lips.
-A client who is dying can experience dehydration. Applying lip balm to the client's lips promotes
comfort.
-Clients who are dying often manifest ineffective breathing patterns. The nurse should position the client
with the head of the bed elevated to ease the breathing process. If the client is experiencing congestion
or nausea, the nurse should position the client on his side.
A nurse in an emergency department is assessing a client who was in a motor-vehicle crash. The client
has a BAC of 0.18% and states, "I would never drink and drive." This is demonstrating use of which
defense mechanism? - ANS Denial
Client refuses to acknowledge the reality of a situation.
rationalization - ANS pt tries to use logical argument to excuse unacceptable behavior
intellectualization - ANS occurs when a client uses reasoning or logic to prevent thinking about emotional
aspects of a situation.
Projection - ANS occurs when a client attributes his feelings as the feelings of another person.
A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is experiencing
moderate placental abruption. What should the nurse do? - ANS Insert a large-bore IV catheter.
, A 16-18 gauge IV catheter is to be inserted into the client's brachial artery because fluid volume and
blood replacement might be necessary to correct defects in coagulation.
Also:
-insert an indwelling urinary catheter for the client who is experiencing moderate placental abruption
because continual urinary output assessment is a secondary method of measuring maternal organ
perfusion.
-closely and constantly monitor the mother and fetus because this is a life-threatening condition.
Therefore, continuous electronic fetal monitoring is mandatory and the nurse should document and
report any change in the fetal or maternal condition to the provider immediately.
-Do not perform any vaginal examinations and the client should be placed on pelvic rest. The amount of
bleeding is assessed by checking perineal pads and bed pads. Also, the nurse should assess the client's
laboratory values for decreased hemoglobin and hematocrit levels.
A nurse is planning care for a client who has a benign chondroma of the tibia. Which of the following
interventions should the nurse plan to include? - ANS Palpate for changes in the muscle of the affected
extremity.
The nurse should palpate to monitor for changes such as muscle spasm, atrophy, or swelling. These
manifestations indicate enlargement of the tumor.
Also:
-remind client of non-weight-bearing status
-pain management is required for pts who have a malignant tumor. BENIGN tumors are managed w/
analgesics & heat/cold therapy
A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum hemorrhage.
What actions should the nurse take immediately? - ANS Massage the client's fundus
The greatest risk to the client is hemorrhage. Massaging the client's fundus expels clots and promotes
contractions.
A nurse is providing family education for a client who wishes to conceive...the nurse should identify that
ovulation is expected to occur on which of the following calendar dates? - ANS D-the 19th.- The nurse
should teach the client that ovulation is expected to occur 13-15 days after day one of her menses.
Ovulation signals the beginning of the secretory phase of the endometrial cycle. Knowing when
ovulation is expected to occur helps the client identify periods of fertility to increase her chances of
conception.
A nurse in an acute care mental health facility is planning care for a client who has bipolar disorder and
who is experiencing acute mania. What action should the nurse take?
- encourage client to take part in daily group meetings (no, they should have one-to-one activities)
-allow client to pick from a variety of activities on the unit (no nurse should provide scheduled meals &
rest periods)
- assign the client to a semiprivate room (no, reduce stimuli and assign to a PRIVATE room w reduced
noise/lighting)
- provide client w finger foods(YES, pts experiencing mania are often unable to sit and eat, finger foods
allow them to get up and move around - ANS Provide the client with finger foods to eat.
(pts experiencing mania are often unable to sit and eat * can become dehydrated & lose weight, finger
foods (sandwiches) allow pt to eat while standing/walking & obtain nutrition even though she cannot sit
down for a meal)
A nurse is caring for an infant who has Tetralogy of Fallot. The nurse notes that the infant exhibits a
sudden onset of cyanosis and is hyperpneic. What action should the nurse take? - ANS Place the infant in
a knee-chest position.
,-This maximizes the oxygenation status of the infant during hyper-cyanotic episodes
-The nurse should administer 100% oxygen via facemask to the infant during hypercyanotic episodes.
-The nurse should administer morphine subcutaneously or through an existing IV line during
hypercyanotic episodes.
-The nurse should initiate or increase the rate of IV fluids to the infant during hypercyanotic episodes.
A nurse is providing discharge teaching to a client following gastric bypass surgery for management of
obesity. What is a client statement that indicates understanding of the teaching? - ANS "I will remain in a
reclining position for 30 minutes after I eat"
Following gastric bypass surgery, clients are at risk for dumping syndrome. Remaining in a reclining
position slows gastric emptying and minimizes the risk of dumping syndrome.
R/T Gastric bypass surgery - ANS -The nurse should teach the client that the area between skin folds
should be kept clean and dry. Applying a moisturizing lotion can cause breakdown of the skin.
-The nurse should teach the client that his diet will consist of pureed foods and liquids for a minimum of
6 weeks following surgery. After this period of time, the client can gradually return to a solid diet.
-The nurse should teach the client that gastric bypass surgery results in a loss of intrinsic factor, which is
a protein secreted by the stomach that is necessary for absorption of vitamin B12, and therefore
requires monthly injections of vitamin B12 and iron. Digestive enzymes are not required.
A nurse is teaching a client who has genital herpes simplex virus. What statement should the nurse
include in the teaching about this STI? - ANS "You should cleanse the lesions with a saline solution twice
each day."
The nurse should teach the client to cleanse the lesions twice each day with a saline solution to prevent
secondary bacterial infections.
R/T Genital herpes simplex virus - ANS -The nurse should teach the client to take over-the-counter
analgesics such as acetaminophen, ibuprofen, or aspirin to control pain associated with the infection.
,-The nurse should teach the client that there is no cure for genital herpes. As a courtesy, the client
should contact all sexual partners so they can receive treatment; however, the law does not require
prior sexual partners to be contacted.
-The nurse should teach the client that there is no cure for genital herpes. Antiviral medication like
acyclovir can reduce the symptoms during active infections.
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following
actions should the nurse take? - ANS Apply a thin coating of lip balm to the client's lips.
-A client who is dying can experience dehydration. Applying lip balm to the client's lips promotes
comfort.
-Clients who are dying often manifest ineffective breathing patterns. The nurse should position the client
with the head of the bed elevated to ease the breathing process. If the client is experiencing congestion
or nausea, the nurse should position the client on his side.
A nurse in an emergency department is assessing a client who was in a motor-vehicle crash. The client
has a BAC of 0.18% and states, "I would never drink and drive." This is demonstrating use of which
defense mechanism? - ANS Denial
Client refuses to acknowledge the reality of a situation.
rationalization - ANS pt tries to use logical argument to excuse unacceptable behavior
intellectualization - ANS occurs when a client uses reasoning or logic to prevent thinking about emotional
aspects of a situation.
Projection - ANS occurs when a client attributes his feelings as the feelings of another person.
A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is experiencing
moderate placental abruption. What should the nurse do? - ANS Insert a large-bore IV catheter.
, A 16-18 gauge IV catheter is to be inserted into the client's brachial artery because fluid volume and
blood replacement might be necessary to correct defects in coagulation.
Also:
-insert an indwelling urinary catheter for the client who is experiencing moderate placental abruption
because continual urinary output assessment is a secondary method of measuring maternal organ
perfusion.
-closely and constantly monitor the mother and fetus because this is a life-threatening condition.
Therefore, continuous electronic fetal monitoring is mandatory and the nurse should document and
report any change in the fetal or maternal condition to the provider immediately.
-Do not perform any vaginal examinations and the client should be placed on pelvic rest. The amount of
bleeding is assessed by checking perineal pads and bed pads. Also, the nurse should assess the client's
laboratory values for decreased hemoglobin and hematocrit levels.
A nurse is planning care for a client who has a benign chondroma of the tibia. Which of the following
interventions should the nurse plan to include? - ANS Palpate for changes in the muscle of the affected
extremity.
The nurse should palpate to monitor for changes such as muscle spasm, atrophy, or swelling. These
manifestations indicate enlargement of the tumor.
Also:
-remind client of non-weight-bearing status
-pain management is required for pts who have a malignant tumor. BENIGN tumors are managed w/
analgesics & heat/cold therapy
A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum hemorrhage.
What actions should the nurse take immediately? - ANS Massage the client's fundus
The greatest risk to the client is hemorrhage. Massaging the client's fundus expels clots and promotes
contractions.
