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Kaplan Question Trainer Test 3
Terms in this set (23)
The client has a diagnosis of a ruptured lumbar disc. The nurse anticipates which assessment finding?
Paresthia in the affected leg (lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities)
The nurse cares for the multipara client who delivered an infant 1 hour ago. The nurse observes the client's breasts are soft, the uterus is boggy to the right of the midline and 2 cm below the umbilicus, and there is moderate lochia rubra. It is most important for the nurse to take which action?
Off the client a bedpan. (boggy uterus deviated to the right indicates full bladder, encourage client to void)
The parent brings a 9-month-old infant to the pediatric office with a fever of 102.2 F and frequent vomiting. The nurse expects to find which reflex?
Babinski reflex (disappears around 12 months)
The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expect the client to present?
Want to discuss and plan meals. (display a marked preoccupation with food)
The nurse provides care for a 2-day-old client. The neonate will not take formula from the parent or the nurse. Which is the priority nursing diagnosis?
A client has just indicated a wish to commit suicide. The client then asks the nurse not to tell anyone. Which action by the nurse is best?
Report the client's wish to commit suicide to the health care provider.
The nurse receives report from the previous shift. In which order does the nurse see these clients?
1) The client 1 day post-op with an epidural catheter in place
2) The client diagnosed with cardiomyopathy being evaluated for a heart transplant
3) The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400
4) The client post coronary artery bypass graft having the AV wires removed at 1500.
The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for the client. Which result indicates the tube feeding can begin?
The contents aspirated from the NG tube have a pH of 3. (stomach contents are acidic)
The client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the most appropriate nursing action if the client's IV infiltrates?
Call the healthcare provider and recommend the IV medication be changed to PO. (
The client is diagnosed with a hiatal hernia. Which information is the nursing assessment most likely to reveal?
Reports awakening at night with heartburn. (classic symptom associated with reflux)
The client is admitted with irritable bowel syndrome. The nurse anticipates the client's history will reflect what information?
Pattern of alternating diarrhea and constipation.
The nurse plans a diet for a child client diagnosed with cystic fibrosis. Which dietary requirement does the nurse consider? (Select all that apply)
The client is learning to self-administer insulin. Which observation indicates to the nurse the client needs further teaching?
The client administers the insulin while it is still cold from the refrigerator.
The client undergoes hospital admission for regulation of insulin dosage. The client takes 15 units of isophane insulin at 0800 every day. At 1600, which nursing observations indicate a complication from the insulin? (select all that apply).
The nurse cares for the client one after a thoracotomy. Nursing actions in the care plan include turn, cough, and deep breathe q2h. Which does the nurse understand to be the purpose of this nursing action?
Promote ventilation and prevent respiratory acidosis.
The client is to have an intravenous pyelogram (IVP). Nursing management includes which action?
Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
A newborn client at 34 weeks gestation weighs 4lb 10 oz (2.12 kg) and has mottling of the skin and acrocynosis with irregular respirations of 60 breaths per minute. Which newborn problem does the nurse suspect the client is experiencing?
The client is receiving imipramine. It is most important for the nurse to instruct the client to immediately report which symptoms? (Select all that apply.)
Vomiting and diarrhea
(It is a tricyclic antidepressant)
The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation most likely indicates bulimia?
Ulcerated oral mucous membranes.
The neonate weighing 7lb 4oz (3.2kg) with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Because the infant's mother is diagnosed with type 1 diabetes, the nurse knows the infant is at greatest risk for developing which problem?
Hypoglycemia (infant still has high insulin output after birth)
The nurse observes the student nurse care for the client. The student nurse wears a gown and gloves in addition to following standard precautions. The nurse determines care is appropriate if the student nurse performs which activity?
Changes the dressing for a client with a draining abscess.
The nurse cares for the client after an electroconvulsive therapy (ECT) treatment. The nurse reports which observation to the healthcare provider?
The nurse cares for the elderly client receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take first?
Decreases the IV rate to 20 mL/h and notifies the healthcare provider.
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