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Related Flashcards
Cards In This Set
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A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following
findings, if assessed by the nurse, would indicate a possible complication? |
The client’s urine test is positive for glucose and acetone
abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency
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A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), Which is the BEST indication that the patient’s nutritional status has improved after 4 days?
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The patient’s albumin level is 4.0mg/dL.
correct–albumin levels are best indicators of long-term nutritional status
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A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
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Avoid eating large meals that are high in simple sugars and liquids
correct-basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals,and reducing intake of carbohydrates
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The nurse is assigned to work with the parents of a retarded child. Which of the following should the
nurse include in the care plan for the parents? |
Perform a family assessment to assist in the planning of intervention
correct–assessment, this will help the nurse to know where the family is in regard to grieving,
coping, etc. |
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The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who
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Produce minimal amounts of insulin
correct–oral hypoglycemic agents are administered to type II (non-insulin-dependent) clients who are able to produce minimal amounts of insulin
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A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding.Which of the following statements, if made by the client, would suggest to the nurse placenta previa as the cause of the bleeding?
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“I feel fine, but the bleeding scares me.”
correct–placenta previa is characterized by painless vaginal bleeding
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The nurse is caring for an 80-year-old client with Parkinson’s disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?
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Maintain optimal function within the client’s limitations.
correct–irreversible disease that leads to permanent physical limitations
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The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two
hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions? |
Remove the dressing and replace it with a more absorbent dressing.
correct–expected that a stab wound will continue to drain until the wound seals; nurse should
keep wound clean and dry |
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The nurse knows which of the following would be MOST likely to help the family of an emotionally
disturbed client manage behaviors at home after discharge from inpatient treatment? |
Refer the family to Alliance for the Mentally Ill meetings for educational programs and support
groups correct–this group provides ongoing support and educational information; people who attend have common needs and goals focused on managing the clients’ behavior at home |
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An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should
position the client |
In semi-Fowler’s position.
correct–check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor
and dyspnea resulting from laryngeal edema or laryngospasm) |
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Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
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Fluid volume deficit related to bleeding
correct–abruptio placenta is premature separation of a normally implanted placenta leading to
hemorrhage; fluid volume deficit is a major nursing concern with these clients |
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An elderly client is returned to her room after an open reduction and internal fixation of the left
femoral head after a fracture. It is MOST important for the nursing care plan to include that the client |
cough and deep breathe.
prevents respiratory complications due to immobility following surgery
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A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle
accident. Which of the following symptoms should the nurse expect to see INITIALLY? |
Decreased level of consciousness.
correct–may be confused and stuporous
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The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the
following observations are expected with scoliosis? |
The girl’s thoracic area is asymmetrical.
correct–thoracic area becomes noticeably distorted
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A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push. The nurse should withhold the next dose if which of the following was observed?
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Occurrence of severe hypotension
correct–severe hypotension or bradycardia are signs of an adverse reaction to this medication
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