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? – answer 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 - answerProvide 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? - answerPlace 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? - answer"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 - answer-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? - answer"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 - answer-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? - answerApply 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? - answerDenial
Client refuses to acknowledge the reality of a situation.
rationalization - answerpt tries to use logical argument to excuse unacceptable behavior
intellectualization - answeroccurs when a client uses reasoning or logic to prevent
thinking about emotional aspects of a situation.
Projection - answeroccurs 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? - answerInsert 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? - answerPalpate 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 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? – answer 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 - answerProvide 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? - answerPlace 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? - answer"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 - answer-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? - answer"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 - answer-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? - answerApply 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? - answerDenial
Client refuses to acknowledge the reality of a situation.
rationalization - answerpt tries to use logical argument to excuse unacceptable behavior
intellectualization - answeroccurs when a client uses reasoning or logic to prevent
thinking about emotional aspects of a situation.
Projection - answeroccurs 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? - answerInsert 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? - answerPalpate 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
