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
... [Show More] 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 kneechest position This 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? - Burretrol
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 - 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 - Manage pain [Show Less]