A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client’s obstetrical history, the nurse should record:
The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse’s appropriate response is:
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse’s intervention would be to:
A 1000-mL dose of D5W 1⁄2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?
At 38 weeks’ gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:
A 52-year-old client’s abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration
for which she is especially at risk is:
A physician’s order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.
What dosage should the nurse administer to the infant?
A 24-year-old client presents to the emergency department protesting “I am God.” The nurse identifies this as a:
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse’s primary goal is to:
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
A burn victim’s immunization history is assessed by the nurse. Which immunization is of priority concern?
A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus’s head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:
A physician’s order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, “What does salt have to do with high blood pressure?’’ the nurse’s initial response would be:
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