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The nurse is performing a measurement of fundal height in a client whose pregnancy has
reached 36 weeks of gestation. During the measurement the client begins to feel
lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse
understands that which is the cause of the lightheadedness?
1.A full bladder
2.Emotional instability
3.Insufficient iron intake
4.Compression of the vena cava - ANSWER 4.Compression of the vena cava.
Compression of the inferior vena cava and aorta by the uterus may cause supine
hypotension syndrome late in pregnancy. Having the woman turn onto her left side or
elevating the left buttock during fundal height measurement will prevent or correct the
problem. The remaining options are unrelated to this syndrome.
The nursing student is writing a plan of care for a child who presents with an acute head
injury. The nursing instructor reviews the plan of care and praises the student for identifying
which assessment as a priority?
1.
Inspecting the scalp
2.
Pupillary assessment
3.
Airway and breathing
4.
Palpating the child's head - ANSWER 3.Airway and breathing.
1
,The first step in the emergency treatment of child with head injury includes the ABCs-airway,
breathing, and circulation-assessments. The other assessments are included when
evaluating a head injury, but the priority is ABC.
A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's
record, the nurse should expect to note documentation of which characteristic sign of SLE?
1.Fever
2.Fatigue
3.Skin lesions
4.Elevated red blood cell count - ANSWER 3.Skin lesions.
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue
disorder that can cause major body organs and systems to fail. The major skin manifestation
of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue
may occur before and during exacerbation, but these signs and symptoms are vague.
Anemia is most likely to occur in SLE.
The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions
are most appropriate for a child placed in protective isolation for neutropenia? Select all that
apply.
1.
Place the child on a low-bacteria diet.
2.
Change dressings using sterile technique.
3.
Put flowers in a vase with water before placing in the room.
4.
Peel fruits and vegetables before allowing the child to eat them.
5.
Allow individuals who are ill to visit as long as they wear a mask. - ANSWER 1.Place the
child on a low-bacteria diet.
2
, For the hospitalized neutropenic child, flowers or plants should not be kept in the room
because standing water and damp soil harbor Aspergillusand Pseudomonas species, to
which these children are very susceptible. Fruits and vegetables not peeled before being
eaten harbor molds and should be avoided until the white blood cell count rises. The child is
placed on a low-bacteria diet. Dressings are always changed using sterile technique.
Individuals who are ill are not allowed to visit the client.
The nurse is reviewing the laboratory test results for a client who takes 325 mg of
acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What
blood level should the nurse review?
1.Hemoglobin (Hgb)
2.Prothrombin time (PT)
3.Red blood cell (RBC) level
4.Partial thromboplastin time (PTT) - ANSWER 2.Prothrombin time (PT).
PT is used to evaluate the adequacy of the extrinsic system and common pathway in the
clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged.
Many diseases and medications such as salicylates are associated with decreased PTs. PT is
also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen
and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of
the blood and also acts as an important acid-base buffer system. The RBC level is helpful in
identifying the cause of anemia and the presence of other diseases. The PTT is used to
evaluate the intrinsic system and the common pathway of clot formation and is most
commonly used to monitor heparin therapy.
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of
the body. Which finding suggests that an escharotomy may be necessary?
1.Pallor of all extremities
2.Pulse oximetry reading of 93%
3.Peripheral pulses are diminished
4.High pressure alarm keeps sounding on the ventilator - ANSWER 4.High pressure
alarm keeps sounding on the ventilator.
A client with a circumferential burn of the entire trunk likely will be on a ventilator because
of the potential for breathing to be affected by this injury. The high pressure alarm will
3
The nurse is performing a measurement of fundal height in a client whose pregnancy has
reached 36 weeks of gestation. During the measurement the client begins to feel
lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse
understands that which is the cause of the lightheadedness?
1.A full bladder
2.Emotional instability
3.Insufficient iron intake
4.Compression of the vena cava - ANSWER 4.Compression of the vena cava.
Compression of the inferior vena cava and aorta by the uterus may cause supine
hypotension syndrome late in pregnancy. Having the woman turn onto her left side or
elevating the left buttock during fundal height measurement will prevent or correct the
problem. The remaining options are unrelated to this syndrome.
The nursing student is writing a plan of care for a child who presents with an acute head
injury. The nursing instructor reviews the plan of care and praises the student for identifying
which assessment as a priority?
1.
Inspecting the scalp
2.
Pupillary assessment
3.
Airway and breathing
4.
Palpating the child's head - ANSWER 3.Airway and breathing.
1
,The first step in the emergency treatment of child with head injury includes the ABCs-airway,
breathing, and circulation-assessments. The other assessments are included when
evaluating a head injury, but the priority is ABC.
A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's
record, the nurse should expect to note documentation of which characteristic sign of SLE?
1.Fever
2.Fatigue
3.Skin lesions
4.Elevated red blood cell count - ANSWER 3.Skin lesions.
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue
disorder that can cause major body organs and systems to fail. The major skin manifestation
of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue
may occur before and during exacerbation, but these signs and symptoms are vague.
Anemia is most likely to occur in SLE.
The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions
are most appropriate for a child placed in protective isolation for neutropenia? Select all that
apply.
1.
Place the child on a low-bacteria diet.
2.
Change dressings using sterile technique.
3.
Put flowers in a vase with water before placing in the room.
4.
Peel fruits and vegetables before allowing the child to eat them.
5.
Allow individuals who are ill to visit as long as they wear a mask. - ANSWER 1.Place the
child on a low-bacteria diet.
2
, For the hospitalized neutropenic child, flowers or plants should not be kept in the room
because standing water and damp soil harbor Aspergillusand Pseudomonas species, to
which these children are very susceptible. Fruits and vegetables not peeled before being
eaten harbor molds and should be avoided until the white blood cell count rises. The child is
placed on a low-bacteria diet. Dressings are always changed using sterile technique.
Individuals who are ill are not allowed to visit the client.
The nurse is reviewing the laboratory test results for a client who takes 325 mg of
acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What
blood level should the nurse review?
1.Hemoglobin (Hgb)
2.Prothrombin time (PT)
3.Red blood cell (RBC) level
4.Partial thromboplastin time (PTT) - ANSWER 2.Prothrombin time (PT).
PT is used to evaluate the adequacy of the extrinsic system and common pathway in the
clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged.
Many diseases and medications such as salicylates are associated with decreased PTs. PT is
also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen
and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of
the blood and also acts as an important acid-base buffer system. The RBC level is helpful in
identifying the cause of anemia and the presence of other diseases. The PTT is used to
evaluate the intrinsic system and the common pathway of clot formation and is most
commonly used to monitor heparin therapy.
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of
the body. Which finding suggests that an escharotomy may be necessary?
1.Pallor of all extremities
2.Pulse oximetry reading of 93%
3.Peripheral pulses are diminished
4.High pressure alarm keeps sounding on the ventilator - ANSWER 4.High pressure
alarm keeps sounding on the ventilator.
A client with a circumferential burn of the entire trunk likely will be on a ventilator because
of the potential for breathing to be affected by this injury. The high pressure alarm will
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