HESI RN COMPASS EXIT EXAM V2

HESI RN COMPASS EXIT EXAM V2   1. A primipara with a breech presentation is in the transition phase pf labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? Supine with the foot of the bed raised 2. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. what is the priority expected outcome for these classes? Participants can identify at least three coping strategies to use during labor 3. Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio? A self evaluation that identifies how the nurse has met professional objectives and goals. 4. a work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map? Multisicipilinary group 5. An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? Stage 3 6. When meeting with the client and the family, which nursing intervention demonstrates the nurses role as collaborator of care? Coordinating and educating about multidisciplinary services 7. A low potassium diet is prescribed for a client what foods should the nurse try to avoid? Dried prunes 8. A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? Hypotension, rapid weak pulse, and rapid respiratory rate 9. The nurse plans to suction a male client. Who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse osculates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? Use a soft tip rubber suction catheter and avoid deep vigorous suctioning. 10. The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? The nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with? Spinal cord injury 11. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? 12. The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? Frequent blood pressure checks, including readings taken automated machines are recommended 13. A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? Monitor for increased blood pressure and pulse 14. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. what intervention should the nurse implement? Confront the client about the consequences of the behavior. 15. A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell? Place child in knee-chest positionThis pressure reduces the rush of blood flow through the septal hole and improves blood circulation. 16. A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? It will identify someone that can make the decisions for you health care if you are ever in a coma or vegetative state. 17. After eye drops are instilled, which instruction should the nurse provide to the client? Close your eyelids 18. The nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select? A Buretrol Attachment 19. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours 20. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is C) Manage pain 21. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? C) "I understand the need to use those new skills." 23. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? C) Gravida 3 para 1 24. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN 25. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube 26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to D) Restore yin and yang 27. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? B) thrombus formation 28. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) The muscles 29. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? B) Chlamydia 30. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors. 31. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? B) Improve the client's nutrition status 32. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to C) Force fluids and reassess blood pressure 33. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney 34. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? C) Tall peaked T waves 35. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? D) Decreased appetite 36. Which of these statements best describes the characteristic of an effective rewardfeedback system? A) Specific feedback is given as close to the event as possible 37. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to D) Progressive placental insufficiency 38. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? C) Moist, productive cough 39. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? D) No special orders are necessary for this examination 40. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago 41. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? B) A teenager who got a singed beard while camping 42. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 43. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is C) Establish an airway 44. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? D) Notify the healthcare provider of the child's status 45. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? D) Have the client empty bladder 46. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? C) Bed wetting 47. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be takenby the nurse is to: D) open the client's airway 48. A client has an orderfor 1000 ml of D5W over an 8 hour period. The nurse Discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? D) Auscultate the lungs 49. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? C) 72 year-old recovering from surgery after a hip replacement 2 hoursago 50. A nurse observes a family member administer a rectalsuppository by having The client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? B) That was done correctly. Did you have any problems with the insertion? 51. A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) Has died. Which type of precautions is the appropriate type to use when performing postmortem care? C) contact precautions 52. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? B) clean the meatus, begin voiding, then catch urine stream 53. The provider orders Lanoxin (digoxin) 0.125 mg POand furosomide 40mg Every day. Which of these foods would the nurse reinforce for the client to eat atleast daily? B) watermelon 54. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? C) Immediately wash the hands with vigor 55. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” The 56. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? B) Glascow Coma Scale 8, respirations regular 57. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? C) A notarized original of advance directives brought in by the partner 58. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN 59. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? B) Restlessness and increased mucus production 60. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? C) "Clothes are becoming tighter across her abdomen." 61. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? D) Proceed with the triage process in the same manner as any adult client 62. A newly admitted elderly client is severely dehydrated. When planning care for This client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? B) Report hourly outputs of less than 30 ml/hr 63. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with thisdisease? B) Strep throat went through all the children at the day care last month. 64. A nurse assigned to a manipulative client for 5 days becomes awareof feelings for a reluctance to interact with the client. The next action by the nurse shouldbe to A) Discuss the feeling of reluctance with an objective peer or supervisor 65. A client is being treated for paranoid schizophrenia. When the clientbecame loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint 66. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia 67. The provisions of the law for the Americans with Disabilities Act require Nurse managers to B) Provide reasonable accommodations for disabled individuals 68. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? C) "I have diminished sexual function." 69. A school-aged child has had a long leg (hip to ankle)synthetic castapplied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? D) ”I think I remember that standing cannot be done until after 72 hours." The 70. Which statement best describes time management strategies appliedto the role of a nurse manager? C) Set daily goals with a prioritization of the work 71. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated withthis problem include which of these? D) Abdominal mass and weakness 72. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." 73. The nurse manager has been using a decentralized block schedulingplan to staff thenursing unit. However, staff have asked for many changes and exceptionsto the schedule over the past few months. The manager considers self schedulingknowing that this method will D) Improve team morale 74. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? C) Bilirubin 75. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? D) Should be limited to 3-4 cups of milk daily 76. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates C) Flight of ideas 77. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? C) Riding a tricycle 78. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is D) Moist saline dressing 79. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action? A) Leave the room and return five minutes later and give the medicine 80. A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? C) "If I drink, my baby may be harmed before I know I am pregnant." 81. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A) Review the medications the client is receiving 82. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated? B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." 83. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver? B) It assesses a child's development. 84. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child? B) Explain the surgery 1 week prior to the procedure 85. The nurse, assisting in applying a cast to a client with a broken arm, knows that C) The wet cast should be handled with the palms of hands 86. Based on principles of teaching and learning, what is the best initial approach to preop teaching for a client scheduled for coronary artery bypass? C) Assessing the client's learning style 87. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child? A) All lesions crusted 88. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? D) I can switch to a bottle if I need to take a break from breast feeding. 89. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment? B) Medication compliance 90. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care? B) Place client on a pressure reducing support surface 91. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? B) 20 month-old who has just learned to climb stairs 92. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother? C) All the pants have become tight around the waist. 93. What is the most important aspect to include when developing a home care plan for a client with severe arthritis? A) Maintaining and preserving function 94. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent? A) Age of the child 95. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants? C) Provides antibodies 96. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects? A) Red reflex test 97. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? D) Occlusive moist dressing 98. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? B) Large wooden puzzle 99. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the B) Yin, the negative force that represents darkness, cold, and emptiness 100. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." 101. Which type of accidental poisoning would the nurse expect to occur in children under age 6? A) Oral ingestion 102. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? D) Ping-pong 103. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? C) Distended neck veins 104. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? D) Note patterns of increased blood pressure 105. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? C) Confine the percussion to the rib cage area 106. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be A) headed for relapse 107. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for C) Psychomotor retardation or agitation 108. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client? C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." 109. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform? C) Sit without support 110. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? C) Obesity 111. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections 112. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to D) prevent the drug from tissue irritation Skip 113. A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? C. Hearing loss 114. A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? D. Soft, relaxed, nontender uterus 115. A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred? D. A sudden gush of dark blood from the introitus 116. A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? A. The client reports a history of sexual abuse by her father. Correct 117. A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? D. "I need to contact my surgeon immediately if I feel any numbness in my genital area." 118 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. A. Skin tenting B. Flat neck veins C. Weak peripheral pulses 119 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided. Answer mL Correct Responses: "350" 120 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: B. Herbs and spices 121 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? C. Cheeseburger 122 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client? B. Drowsiness 123 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? C. Epistaxis 124 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? C. Count wet diapers to be sure that the infant is having at least six to 10 each day 125 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? C. "Wearing the brace is really important in curing the scoliosis." 126 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: D. Tomato juice 127 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: B. Decrease 128 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: C. Pitting edema is present 129 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: B. Document the findings Correct 130 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? D. Replacement of the uterus through the vagina into a normal position 131 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: B. Recheck the temperature in 4 hours 132 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be: C. Helping the woman empty her bladder 133-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? A. Anxiety 134 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? C. Positive result on d-dimer study 135 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. A. Tachycardia D. Diminished peripheral pulses 136- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? D. Placing the client in a lateral position with the bed flat 137 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? D. Reddish lochia on postpartum day 8 138 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A. Document the findings Correct 139- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? B. "The placenta maintains the body temperature of my baby." Correct 140 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is: B. July 2, 2013 Correct 141 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? A. Steak Correct 142 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? D. White blood cell count of 2500 cells/mm3 143 -Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse? C. Multiple sexual partners 144. When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do? A) Place the infant in a supine or side lying position for sleep 145. A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it B) Reduces the potential for shock 146. The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding? C) Swelling of lower extremity 147. A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be best for the nurse to tell the caregiver? C) Use plain water for the bath, shampooing hair last 148. A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse? D) Gravida 2, Para 1 149. On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, “I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night.” Which nursing diagnoses would be most important for this client? D) Impaired gas exchange related to broncho constriction and mucosal edema 150. A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client? C) Semi-Fowler 151. While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication? C) Dyspnea and cough 152. While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately? C) Serum bilirubin of 12mg 153. The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to A) Rinse the tooth in water before placing it in the socket 154. The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that B) Bones of children are more porous than adults and often have incomplete breaks 155. During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding? C) Rapid shallow respirations with intermittent wheezes 156. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention? D) Decrease in chest wall expansion 157. A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a D) PPD intradermal test 158. The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate? B) Echolalia and a shuffling gait 159. Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults? A)You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods. 160. A 67 year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infraction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is C) Impaired gas exchange