NSG 4800 MAIN EXAM WITH COMPLETE ANSWERS

NSG 4800 MAIN EXAM WITH
COMPLETE ANSWERS




The nurse is monitoring a client in the immediate postpartum period for signs of
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hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
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A .temperature of 100.4°F (38°C)
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B. An increase in the pulse rate from 88 to 102 beats/minute
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C. A blood pressure change from 130/88 to 124/80 mm Hg
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D. An increase in the respiratory rate from 18 to 22 breaths/minute - correct answer-B,
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During the fourth stage of labor, the maternal blood pressure, pulse, and respiration
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should be checked every 15 minutes during the first hour. An increasing pulse is an
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early sign of excessive blood loss because the heart pumps faster to compensate for
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reduced blood volume. A slight increase in temperature is normal. The blood pressure
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decreases as the blood volume diminishes, but a decreased blood pressure would not
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be the earliest sign of hemorrhage. The respiratory rate is slightly increased from
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normal.
b




The nurse in the ambulatory care unit is providing home care instructions to a client
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after cryotherapy for the treatment of malignant skin lesions. Which statement would
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be most appropriate for the nurse to include in the home care instructions for this
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client?
b



"Apply ice to the site to prevent swelling."
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, "Clean the site with alcohol 3 times daily."b b b b b b b



"Apply a warm, damp washcloth if discomfort occurs."
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"Avoid showering or taking baths until seen by the health care provider in 1 week." -
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correct answer-3, Cryotherapy involves the local application of liquid nitrogen to the
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lesion; this causes cell death and tissue destruction. Tissue freezing is followed in 1 to
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2 days by hemorrhagic blister formation; therefore, ice is not applied to the site. The
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application of a warm, damp washcloth intermittently to the site will provide relief of
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any discomfort. The nurse instructs the client to clean the site with the prescribed
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solution to prevent secondary infection. A topical antibiotic also may be prescribed.
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Alcohol would cause irritation to the skin. There is no reason for the client to avoid
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showering or bathing.
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The registered nurse is caring for the following clients. It would be a priority for the
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nurse to initiate a multidisciplinary conference for the client who is
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A.12 years old with Autism who is starting a new school and recently had a URI (upper
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respiratory tract infection)
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B.39 years old, has type 2 Diabetes Mellitus, is homeless and had a recent
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Hemoglobin A1c of 13%
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C.52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine)
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and is employed as a mail carrier
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D.79 years old, has bipolar and schizophrenia, lives alone and reports hearing non
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threatening voices. - correct answer-B
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A client with uncontrolled Diabetes Mellitus would require the greatest number of
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disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work,
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Nutritionist; the other choices do not require as many providers of care to meet their
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needs.
b




A client is scheduled to begin therapy with carbamazepine. The nurse should assess
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the results of which test(s) before administering the first dose of this medication to the
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client?
b



Liver function tests b b



Renal function tests b b



Pancreatic enzyme studies b b



Complete blood cell count - correct answer-D. Carbamazepine may be used to treat a
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seizure disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very
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rarely, fatal aplastic anemia. To reduce the risk of serious hematological effects, a
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complete blood cell count should be done before treatment and periodically thereafter.
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This medication should be avoided in clients with preexisting hematological
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abnormalities. The client also is told to report the occurrence of fever, sore throat,
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pallor, weakness, infection, easy bruising, and petechiae. The results of the remaining
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tests listed in the options are not associated with the use of this medication.
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A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The
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binitial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV)
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binfusion of short-acting insulin is initiated, along with IV rehydration with normal saline.
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bThe serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse
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bwould next prepare to administer which medication?
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An ampule of 50% dextrose
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NPH insulin subcutaneously
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IV fluids containing dextrose
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