NCLEX EXAM - FILE 3- QUESTIONS AND ANSWERS

NCLEX DEC FILE 3 1. Which assessment best determines the effectiveness of Sumatriptan (triptans are used for treatment of Migraines so… Termination of the migraine 2. Pt with schizophrenia is prescribed chlorpromazine (Thorazine – first generation antipsychotic) oral concentrate The medication may cause excessive salivation and no direct skin contact (both correct – not a good question) 3. Which best assessment best determines the pt is developing tardive dyskinesia Twisting, writhing, worm-like movements of tongue 4. Pt with depression is prIscribed Fluoxitine (Prozac) “It may take 3-4 weeks before my mood is elevated” 5. Pt is on Marplan (MAOIs – have the most food interactions) for depression Bananas, smoked fish, and cheese 6. Pt on Lithium Polydypsia (increased thirst), slurred speech, and fine hand tremors 7.Pt is prescribed Lunesta for insomnia Anterograde amnesia (memory loss of events right before taking drug) 8. A 24 yr female gets Triazolam (Halcion) for insomnia at home (remember to use the process of elimination) “The medication will not alter my breathing” 9. A pt is prescribed Venlafaxine and the pt asks what the purpose of medication is, you should state Depression and anxiety 10. . A client who was prescribed atorvastatin Lipitor one month ago calls the triage nurse at the clinic complaining of muscle pain and weakness in his legs. Which statement reflects the correct drug-specific teaching the nurse should provide to this client? Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect 11. A client who has been taking levodopa PO TID to control the symptoms of Parkinson's disease has a new prescription for sustained release levodopa/carbidopa Sinemet 25/100 PO BID. The client took his levodopa at 0800. Which instruction should the nurse include in the teaching plan for this client? You can begin taking the Sinemet this evening, but do not take any more levodopa 12. A client is receiving methylprednisolone Solu-Medrol 40 mg IV daily. The nurse anticipates an increase in which laboratory value as the result of this medication? Serum glucose 13. A client with hyperlipidemia receives a prescription for niacin Niaspan. Which client teaching is most important for the nurse to provide? Expected duration of flushing 14. When assessing an adolescent who recently overdosed on acetaminophen Tylenol, it is most important for the nurse to assess for pain in which area of the body? Abdomen 15. The nurse is preparing the 0900 dose of losartan Cozaar, an angiotensin II receptor blocker ARB, for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? Withhold the scheduled dose 16. An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac Toradol 30 mg IV q6h. Which action should the nurse implement? Administer both medications according to the prescription 17. A nurse is caring for a client who has a depressive disorder and declines electroconvulsive therapy (ECT) despite the provider’srecommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client’s decision? Answer: Autonomy 18. A nurse isreinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make? Answer: Have you considered participating in a sport to help control your aggression 19. A nurse on an inpatient mental health unit is supervising a group of clients in the unit’s dayroom. The nurse failsto respond to the escalating, aggressive behavior of a client eventually becomes violent and injures another client. For which of the following isthe nurse liable? Answer: Negligence 20. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findingsshould the nurse withhold the client’s medications and notify the provider? Answer: WBC count 21. A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first? Answer: The client who is experiencing command hallucinations 22. A nurse isreinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse make? Answer: You should listen to music when you feel stress 23. A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to treat rapid-cycling bipolar disorder. Following the procedure, which of the following action should the nurse take? Answer: Administer oxygen to the client 24. A nurse is caring for a client who has psychiatric symptom disorder. Which of the following actions should the nurse take? Answer: Encourage the client to examine how hisillness behavior affects hisfamily 25. A nurse is caring for a client who recently lost his child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? Answer: Have you had any thoughts of harming yourself 26. A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? Answer: Stand in front of the client when speaking 27. A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? Answer: Naloxone 28. A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findingsshould the nurse identify as manifestations of bulimia nervosa? Answer: -Tooth erosion -Hand calluses -Hypokalemia 29.. nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? Answer: Pupillary dilation 30. A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse includes? Answer: Dietitian 31. A nurse is assisting with discharge planning for a client who needs a day treatment center ad has limited community and financial support. Which of the following referrals should the nurse recommend for inclusion in the client’s discharge plan? Answer: Social worker 32. A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few momentslater,the client cheerfully states, “Now,here is my favorite social worker!” The nurse should identify the client is using which of the following defense mechanisms? Answer: Reaction formation 33. A nurse on an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? Answer: A client who has borderline personality disorder and is pacing restlessly 34. A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statement indicates an understanding of the information? Answer: I will probably feel irritable within 24 hours of my last cigarette 35. A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explainsthe therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts isthe nurse demonstrating? Answer: Veracity 36. A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? Answer: Promote The development of problem-solving skills 37. A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider? Answer: Feeling of hopelessness 38. A nurse on a mental health unit is prioritizing care for a group of clients. Which of the following actions should the nurse take first? Answer: Administer haloperidol to a client who has schizophrenia and is yelling at other clients. 39.A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? Answer: Offer liquid supplements to the client 40. A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and beginsthrowing objects at staff and other clients. After calling for assistance. Which of the following actions should the nurse take next? Answer: Tell the client calmly to sit down 41. A nurse caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse reports to the charge nurse? Answer: A client who is manic has been pacing the unit for several hours 42. A nurse is collecting data from a client who istaking valproic acid for the treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider? Answer: Bleeding gums 43. A nurse is attempting to resolve an ethical dilemma that involves a client’s medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next? Answer: Determine the benefits and consequences of respecting the client’s medical Decisions 44. A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? Answer: I will snap a rubber band on my wrist when I feel anxious about riding in a car 45.A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond? a. that is called a caput succedaneum. it will absorb and cause no problems* 46.A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the hospital. Which instruction should the nurse include in the discharge teaching plan? b. monitor skin and eyes for yellow tinge 47.The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/min, respiratory rate 16 breaths/min, andblood pressure 130/74. What action should the nurse implement? c. document the vital signs in the record 48.A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin E drug. How should the nurse respond? d. you may be at higher risk for having a spontaneous miscarriage * 49.A pregnant woman who is at 10-weeks’ gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used toidentify Down Syndrome * 50.A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, menopur) and HCG. Which side effect should the nurse tell the client to report immediately? c. nausea and vomiting 51.The HCP prescribes 10 units/L of oxytocin (Pitocin) via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Which finding would causethe nurse to immediately discontinue the oxytocin? d. contraction duration of 100 seconds * 52.The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority should the nurse address to ensure the newborn’s survival? c. heat loss 53.One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? a. check the differential, since the WBC is normal for this client * 54.The nurse is performing a newborn assessment. Which symptom, if present in a newborn would indicate respiratory distress? b. flaring of the nares * 55. A client receiving epidural anesthesia begins to experience nausea and becomes paleand clammy. What intervention should the nurse implement first? Raise the foot of the bed 56. What is the normal bilirubin at 1 day old? A. The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. 57. How do we lower the levels if they are not severe? This infant's bilirubin is beginning to climb, and the infant should be monitored to prevent further complications. 58. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestationin preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor duringthe administration of this drug? Monitoring maternal and fetal heart rates is most important when terbutaline is beingadministered. 59. A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is thisnewborn likely to have exhibited? Choking, coughing, and cyanosis. 60. What does a child in respiratory distress look like? Apneic spells and grunting with prematurity or sepsis 62. What does a diaphragmatic hernia look like? Scaphoid abdomen and anorexia 63. A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot."Which explanation should the nurse give to this anxious client? There's a strong, tough membrane there to protect the baby so you need not be afraidto wash or comb his/her hair. 64. A client who is attending antepartum classes asks the nurse why her healthcareprovider has prescribed iron tablets. The nurse's response is based on what knowledge? It is difficult to consume 18 mg of additional iron by diet alone. 65. What is megaloblastic anemia caused by? Folic acid deficiency 66. A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A home pregnancy test can be used right after your first missed period. 67. A 28-year-old client in active labor complains of cramps in her leg. What interventionshould the nurse implement? Extend the leg and dorsiflex the foot 68. When do the anterior and posterior fontanels close? anterior fontanel closes at 12 to 18 months and the posterior by the end of the secondmonth. 69. When assessing a client who is at 12-weeks gestation, the nurse recommends that sheand her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? 30 weeks gestation 70. The nurse should encourage the laboring client to begin pushing when? The cervix is completely dilated. 71. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? Have the client breathe into her cupped hands 72. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does notcross the suture line is a newborn variation known as... a cephalohematoma, caused by forceps trauma and may last up to 8 weeks. 73. When does the head return to its normal shape? 7-10 days 74. What did Nurse theorist Reva Rubin describe? The initial postpartum period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, andcloseness to families and the newborn. 75. A couple, concerned because the woman has not been able to conceive, is referred to ahealthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which post procedure complaint indicates that the fallopian tubes are patent? Shoulder pain 76. Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" Lying prone with a pillow on the abdomen 77. he nurse is caring for a newborn who is 18inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10inches. Based on these physical findings, assessment for which condition has the highest priority? a. Hyperthermia 78.A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client? a. When there is no significant vaginal bleeding. 79.A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, menopur), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately? c. Rapid increase in abdominal girth 80 .At 0600 while admitting a woman for a scheduled repeat Caesarean section (C-section),the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a. Inform the anesthesia care provider 81.Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothersvaginal bleeding and finds that she has saturated two pads in 30minutes and has a boggy uterus. What action should the nurse implement first? a. Perform fundal massage until firm 82. A nurse in prioritizing care for four clients. Which of the following clients should the nurse assess first? An adolescent who has sickle cell anemia and slurred speech 83. A nurse is providing teaching to a parent of a child who has cystic fibrosis and a new prescription for dornase alfa. Which of the following instructions should the nurse include the teaching? “Store the medication in the refrigerator.” 84. A nurse is caring for a child who has bacterial meningitis. Which of the following criteria indicates the nurse should remove the child from droplet precautions? Antibiotics initiated 24 hr ago 85. A nurse is assessing a school age child who has type 1 DM. The nurse notes that the child is diaphoretic. Which of the following actions should the nurse take? Obtain a blood glucose level 86. A nurse is caring for a child who is terminally ill. The parents tell the nurse that their child is going to be fine because they heard about another child who survived the same illness. Which of the following responses should the nurse make? “Tell me what you know about your child’s illness.” 87. A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should the nurse expect? Steatorrhea 88. A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching? Apply bactericidal ointment to lesions 89. A nurse is preparing to administer naproxen 150 mg PO to a child who is experiencing pain. Available is naproxen 125 mg/ 5 ml solution. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 6 ml 90. A nurse is assessing a 6-month old patient at a well-child visit. Which of the following findings should the nurse expect? a. Closed posterior fontanel (8 weeks). 91. A nurse is caring for a 2-year old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose? a. ?? 92. A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client’s plan of care? a. Encourage fluid intake at and between meals. 93. A nurse is planning care for a child who has suspected epiglottis. Which of the following actions should the nurse take? a. place the child in an upright position 94. A nurse is instructing a group of clients regarding calcium rich food. Which of the following should the nurse include in the teaching as the best source of calcium? a. 1 cup milk 95. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says “ I don’t understand why my child is so upset. I’ve never seen my child act this way around others before.” Which of the following statements should the nurse make? a. “This is a normal, expected reaction for a child of this age.” 96. A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child’s cooperation? a. Offer the child a choice of taking it with juice or water. 97. A nurse is caring for a client who requires droplet precautions. Which of the following Personal protective equipment should the nurse wear when setting up the meal tray? a. Mask 98. A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of The following actions by the client indicates an understanding of the teaching? a. The client holds his breath 10 seconds after inhaling the medication. 99. A nurse is caring for a 2-month-old infant who is post-operative following surgical repair of a cleft lip. Which of the following actions should the nurse take? a. Administer ibuprofen as needed for pain. 100. A nurse is caring for a child who has Kawasaki disease. Which of the following systems Should the nurse monitor in response to this diagnosis? a. Cardiovascular 101. A nurse is providing teaching to a client who has oral candidiasis and a new script for Nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching? a. “I will store the medicine at room temp” 102. A nurse is caring for a child who has been diagnosed with pertussis. Which type of precautions should the nurse take when caring for this child? Droplet precautions 103.A 7-year old girl is being seen at a healthcare clinic; the nurse suspects that the child is being neglected and physically abused at home. Beyond physical markings on the child, which of the following can also indicate signs of a child being abused or neglected? Select all that apply. The patient is wearing dirty, poorly-fitted clothes The patient misses school approximately once per week The child has body odor and rotting teeth 104.A nurse who works in the pediatric unit walks into a 3-year-old patient’s room and finds him lying on the floor. His parents are with him and they tell the nurse, “he fell out of bed!” Which response from the nurse is the most appropriate? Assist the patient back to bed, assess him for injuries and file an incident report 105.The nurse is conducting a physical examination in the ER of a child following a comprehensive health history. What should be the focus of the physical examination? Chief complaint 106.Which would be least effective in gaining the cooperation of a toddler during a physical examination? Tell the child that another child the same age wasn’t afraid. 107.The nurse is preparing a nursing care plan for an 8-year old child hospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the “building a trusting relationship” stage? Select all that apply. Preparing the child for a procedure by playing games Explaining in simple terms what will be happening during surgery Giving the child a favorite toy to cuddle with following a painful procedure 108.A nurse is caring for a 13-year-old girl who is sexually active and whose partner is her 19-yearold boyfriend. The girl asks the nurse not to tell her parents about her sexual activity. This patient’s situation is best described as: statutory rap 109. An 11-year-old boy has been diagnosed with depression after his parents’ divorce. The nurse understands that depression in most children of this age most commonly manifests as: Lack of interest with friends and families 110.During the health history, the mother of a 4-month-old child tells the nurse she is concerned that her baby is not doing what he should be at this age. What is the nurse’s best response? “Tell me what concerns you.” 111.What is the role of the peer group in the life of school-age children? Provides them with security as they gain independence from their parents. 112.For which child would nonopioid analgesics be recommended? A child with juvenile arthritis 113.A nurse is working with a child who has a learning disability because she is unable to discriminate between different speech sounds. This disorder is most accurately described as: phonological processing deficit 114.The nurse is caring for an 11-year-old child who is experiencing pain related to chemotherapy treatment. What is a behavioral factor that might affect the child’s pain experience? Participation in normal routine activities 115. A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant? a. Trendelenburg? 116. A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. The amount available is 0.125mg tab. The client’s current vital signs are: BP 144/96, hear rate 54/min, respirations 18/min, and temperature 98.6 F. Which of the following actions should the nurse take? a. Withhold for decreased pulse rate. 117. A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? a. “My teacher says my child has to squint to see the board.” 118. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries Do to a motor-vehicle crash. Identify the sequence of actions the nurse should take. 1. Open airway using a jaw-thrust maneuver 2. Determine effectiveness of ventilator efforts 3. Establish IV access 4. Glasgow Coma Scale assessment 5. Remove clothing for a thorough assessment. 119. A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching? a. “I will give my child strained carrots and mashed egg yolks.” 120. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? a. Inspect the mouth for signs of inhalation injuries 121. A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? a. Private room 122. A nurse is reviewing the lab findings for a client who has ITP. Which of the following findings should the nurse expect to be decreased? a. Platelets 123. A nurse is assessing a client who has SLE. Which of the following findings should the nurse expect? a. Facial rash 124. A nurse is creating a plan of care for a school-age child who has nephrotic syndrome. Which of the following interventions should the nurse include? (Select all that apply) • Provide a low-sodium diet • Assess for protein in the urine • Obtain a daily weight 125. A nurse in a pediatric unit is caring for a school-age child following a cardiac catheterization. Which of the following interventions would the nurse take? • Keep the affected extremity straight for 6 hrs. 126. A nurse is teaching a parent of a toddler about administering digoxin. Which of the following statements by the parent indicates understanding of the teaching? • “I should give my child water after giving the medication.” 127. A nurse is caring for a 9-year-old child who has major burns to her face and upper torso. Which of the following actions should the nurse take first? • Give pain medication 128. A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following should the nurse include in the plan of care? • Cleanse the gums with saline soaked gauze 129. A nurse in a community health clinic is assessing the needs of a single parent who has three young children and works full time. Which of the following resources should the nurse recommend? • Respite child care 130. A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 4. Women who have implants are often able exclusively to breastfeed. 131. A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby’s and mother’s infection? 4. Candida albicans. 132. A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 133. A woman, 26 weeks’ gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 134. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 4. Provide the client with supervised instruction on baby care skills. 135. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 2. Fluid volume deficit. 136. A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client’s health care practitioner? 1. Foul-smelling lochia. 137. A client is 36 hours post–cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 4. Absent bowel sounds. 138. A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 139. The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which assessment finding warrants immediate intervention by the nurse? C. Bluish tinge to the tongue 140. A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which information is most important for the nurse to provide the client? A. When there is no significant vaginal bleeding 141. A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and no contractions are noted on the external monitor. Which intervention should the nurse implement? A. Weight perineal pads 142. The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) A. Admission weight of 4 pounds, 15 ounces (2244 grams) B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm). 143. A client at 20 weeks gestation comes to the antepartum clinic complaining of vaginal warts (human papillomavirus). What information should the nurse provide this client? A. Treatment options, while limited due to the pregnancy, are available 144. One week after missing her menstrual period, a woman performs an OTC pregnancy test and it is positive. Which hormone is responsible for producing the positive result? C. Human chorionic gonadotrophin 145. A new mother, who is lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge? B. Continue prenatal vitamins with B12 while breast feeding 146. A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client’s use of this substance? Answer: Hypertension 147. A nurse in a mental health facility is caring for a client who has dementia. The client’s agitation is increasing. Which of the following actions should the nurse take first? Answer: Offer diversionary activities 148. A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? Answer: Determine the client’sintentions 149. A nurse isreinforcing discharge teaching with a client who has a new prescription for alprazolam. Which of the following instructions is the priority for the nurse to include? Answer: Do not drive until your reaction to the medication is determined 150. A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news report about military action comes on the television, the client says to the nurse, “My youngest child died 6 months ago while serving in the military.” Which of the following responses should the nurse make? Answer: -This must be very difficult time for you -Your child’s death must be a terrible loss -Tell me something you remember about your child 151. A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania, Which of the following interventions should the nurse include to improve the nutritional status of the client? Answer: Have the client’sfavorite snacks available at all times. 152. A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? Answer: Projects blame onto others 153. A nurse on and inpatient unit is assisting with a group therapy session. During the session, a client begins to shout using aggressive language. Which of the following statements should the nurse make to the client? Answer: When you raise your voice, it makes me feel uncomfortable and unsafe.” 154. A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client’s confidentiality? Answer: The nurse places the client’s diagnosis on the white board in the client’s room 155. A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findingsisreferred to as a negative symptom of schizophrenia? Answer: Apathy