138267231 Nle Reviewerdianemaydee

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PART INURSING PRACTICE IFoundation of Professional NursingPractice TEST I - Foundation of Professional Nursing Practice1.The nurse In-charge in laor and deli!er" unit ad#inistered a dose of terutaline to a client $ithout chec%ing the client&s 'ulse. The standardthat$ould e used to deter#ine if the nurse $as negligent is( a . T h e ' h " s i c i a n & s o r d e r s .

.The action of a clinical nurse s'ecialist $ho is recogni)ed e*'ert inthe field. c.Th e state#en t in the drug lite ratu re aout ad#inist rati on of terutaline. d. The actions of a reasonal" 'rudent nurse $ith si#ilar educationand e*'erience.

+.Nurse Trish is caring for a fe#ale client $ith a histor" of GI leeding,sic%le cell disease, and a 'latelet count of ++,/l. The fe#ale client isdeh"drated andrecei!ing de*trose 0 in half-nor#al saline solution at10 #lhr. The client co#'lains of se!ere one 'ain and is scheduled torecei!e a dose of #or'hine sulfate.In ad#inistering the #edication, NurseTrish should a!oid $hich route2

A . I 3 I 4c . 5 r a l d . S C

6. 7r. Garcia $rites the follo$ing order for the client $ho has een recentl"ad#itted 87igo*in.1+0 #g P.5. once dail".9 To 're!ent a dosage error,ho$ should thenurse docu#ent this order onto the #edicationad#inistration record2a.87igo*in .1+0 #g P.5. once dail"9

. 87 ig o* in . 1+ 0 #g P. 5. on ce da il "9c.87igo*in .1+0 #g P.5. once dail"9d.87igo*in .1+0 #g P.5. once dail"9

:. A ne$l" ad#itted fe#ale client $as diagnosed $ith dee' !ein thro#osis.;hich nursing diagnosis should recei!e the highest 'riorit"2a.Ineffecti!e 'eri'heral tissue 'erfusion related to !enous congestion.

. Ri s% fo r in 4I? client $ho is co#'lainingof nausea.c.A +@ "ear-old client ad#itted for deh"dration $hose intra!enous>I3? has infiltrated.d.A @6 "ear-old 'ost o'erati!e&s ado#inalh"sterecto#" client of three da"s $hose incisional dressing is saturated $ithserosanguinous [email protected] Gail 'laces a client in a four-'ointrestraint follo$ing orders fro# the'h"sician. The client care 'lan should include(a.Ass ess te#'erature fr euent l"..Pro!ide di!e rs ionalacti!ities.c.Chec% circulation e!er" 10-6 #inutes.d.Sociali)e $ith other 'atients once a shift.B.

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A #ale client $ho has se!ere urnsis recei!ing + rece'tor antagonistthera'". The nurse In-charge %no$s the 'ur'ose of this thera'" is to(a . Pre! e ntstr ess ulc er .=loc% 'rostaglandin s"nthesisc.Fa cil ita te 'ro tei n s "nt hes is. d.E nha nce gas e*c han ge D.The doctororders hourl" urine out'ut #easure#ent for a 'osto'erati!e#ale client. The nurse Trish records the follo$ing a#ounts of out'ut for +consecuti!ehours( D a.#.( 0 #l a.#.( @ #l. =ased on these a#ounts,$hich action should the nurse ta%e2a.Inc reas e the I.3 . flu id inf us ionrate.Irrigate the ind$elling urinar" catheter c . N o t i f " t h e ' h " s i c i a n d.Continue to #onitor and record hourl"ur in e out'u t.Ton", a as%etall 'la"er t$ist his right an%le $hile 'la"ing on the courtand see%s care for an%le 'ain and s$elling. After thenurse a''lies ice tothe an%le for 6 #inutes, $hich state#ent " Ton" suggests that icea''lication has een effecti!e2a.84" an%le loo%s less s$ollen

no$9..84" an%le feels $ar#9. c.84" an%le a''ears redder no$9.d.8I need so#ething stronger for 'ain relief91.The 'h"sician 'rescries a loo' diuretic for aclient. ;hen ad#inisteringthis drug, the nurse antici'ates that the client #a" de!elo' $hichelectrol"te i#alance2a . " ' e r n a t r e # i a . " ' e r % a l e # i a c . " ' o % a l e # i a d . " ' e r ! o l e # i a11.She finds out that so#e #anagers ha!e

ene!olent-authoritati!e st"le of #anage#ent. ;hich of the follo$ing eha!iors $ill she e*hiit #ost li%el"2a.a!e condescending trust andconfidence in their suordinates..Gi!es econo#ic and ego a$ards.c.Co##unicates do$n$ard to staffs.d.Allo$s decision#a%ing a#ong suordinates.1+. Nurse A#" is a$are that the follo$ing is true aout functional nursinga.Pro!ides continuous, coordinatedand co#'rehensi!e nursingser!ices..5ne-to-one nurse 'atie nt ratio .c.E# 'hasi )e the use of grou'collaoration.d.Concentrates on tas%s and acti!ities. 16.;hich t"'e of #edication order #ight read 3ita#in H 1 #g I.4. dail"

6da"s2a. S i n g l e o r d e r .Standard $rit ten order c . S t a n d i n g o r d e r d . S t a t o r d e r 1:.A fe#ale client $ith a fecali#'action freuentl" e*hiits $hich clinical#anifestation2a . I n c r e a s e d a ' ' e t i t e . Jo ss of ur ge to de fec at ec . ar d, r o$ n,for#ed stoolsd.Jiuid or se#i-l iuid stools 10.Nurse Jinda 're'ares to 'erfor# an otosco'ic e*a#ination on a fe#aleclient. For 'ro'er !isuali)ation, the nurse should 'osition the clientKsear "(a.Pulling the loule do$n and ac%.Pulling the heli* u' and for$ardc.Pulling the heli* u' and ac%d.Pullingthe loule do$n and for$ard1@.

;hich instruction should nurse To# gi!e to a #ale client $ho is ha!inge*ternal radiation thera'"(a.Pro tect the irri tated s%in fro#sunlight.. Eat 6 to : ho urs efor e treat#e nt.c .; as h th e s% in o! er re gu la rl ". d.A''l" lotion or oil to the radiated area $hen

it is red or sore.1B.In assisting a fe#ale client for i##ediate surger", the nurse In-charge isa$are that she should(a.Encourage the client to !oidfollo$ing 'reo'erati!e #edication..E*'lore the client&s fears and an*ieties aout the surger".c.As sist the cl ient in re#o! ingden tures and nai l 'olis h.d .En coura ge the cli ent to dri n% $ater 'rior to surger". 1D. A #ale client is ad#itted and diagnosed $ithacute 'ancreatitis after aholida" celeration of e*cessi!e food and alcohol. ;hich assess#entfinding reflects this diagnosis2a. =lood 'ressure ao!enor#al range..Presence of crac%les in oth lung fields.c."' era cti !e o$ el sou nds d.Sudden onset of continuouse'igastric and ac% 'ain.1.

;hich dietar" guidelines are i#'ortant for nurse 5li!er to i#'le#ent incaring for the client $ith urns2a.Pro!ide high-fier, high-fatdiet.Pro!ide high-'rotein, high-caroh"drate diet.c.4onitor inta%e to 're!ent $eight gain.d.Pro!ide ice chi's or $aterinta%e.+.Nurse a)el $ill ad#inister a unit of $hole lood, $hich 'riorit"infor#ation should the nurse ha!e aout the client2a. =lood 'ressure and'ulse rate.

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. e i g h t a n d $ e i g h t . c .Ca lciu# an d 'otass iu# le!els d . g a n d c t l e ! e l s . +1. Nurse 4ichelle $itnesses a fe#ale clientsustain a fall and sus'ects thatthe leg #a" e ro%en. The nurse ta%es $hich 'riorit" action2a .Ta%es a s et o f !i tal s igns . .Ca ll the radi ol og" de'art#ent for L-ra".c.Reassure the client that e!er"thing $ill e alright.d.I##oili)e the leg efore #o!ing theclient.++.A #ale client is eing transferred to the nursing unit for ad#ission after recei!ing a radiu# i#'lant for ladder cancer. The nurse in-charge

$ouldta%e $hich 'riorit" action in the care of this client2a.Place cl ient on re!erse isolat ion..Ad#it the cl ient in to a 'r i!ateroo# .c.Encou rage the client to t a%e freuen t rest 'er iods .d.En cou rage fa#i l" and friends to !isi t. +6.A ne$l" ad#itted fe#aleclient $as diagnosed $ith agranuloc"tosis. Thenurse for#ulates $hich 'riorit" nursing diagnosis2a . C o n s t i ' a t i o n . 7 i a r r h e a c . R i s %

f o r i n f e c t i o n d.7ef ic ient %no$ledge +:.A #ale client is recei!ing total 'arenteral nutrition suddenl" de#onstratessigns and s"#'to#s of anair e#olis#. ;hat is the 'riorit" action " thenurse2a. Notif" the 'h"s ic ian . .Place the client on the left side in the Trendelenurg'osition.c.Place the client in high-Fo$lers 'osition.d.Sto' the total 'arenteral nutrition.+0.Nurse 4a" attends an educationalconference on leadershi' st"les. Thenurse is sitting $ith a nurse e#'lo"ed at a large trau#a center $ho statesthat the leadershi' st"le at the trau#a center istas%-oriented anddirecti!e. The nurse deter#ines that the leadershi' st"le used at thetrau#a center is(a . A u t o c r a t i c . . J a i s s e ) - f a i r e . c . 7 e # o c r a t i c . d . S i t u a t i o n a l [email protected] 'h"sician orders 7S 0 cc $ith HCl 1 #Eliter at 6 cchr. Thenurse in-charge is going to hang a0 cc ag. HCl is su''lied + #E1cc. o$ #an" cc&s of HCl $ill e added to the I3 solution2a . . 0 c c . 0 c c c . 1 . 0c c d . + . 0 c c +B.A child of 1 "ears old is to recei!e : cc of I3 fluid in an D hour shift.The I3 dri' factor is @. The I3 rate that $illdeli!er this a#ount is(a . 0 c c h o u r . 0 0 c c h o u r c . + : c c h o u r d . @ @ c c h o u r +D.The nurse is a$are that the

#ost i#'ortant nursing action $hen a clientreturns fro# surger" is(a.Assess the I3 for t"'e of fluid and rate of flo$..As sess the cl ientfor 'resence of 'ain.c.Assess the Fole" catheter for 'atenc" and urine out'utd.Assess the dressing for drainage.+.

;hich of the follo$ing !ital sign assess#ents that #a" indicatecardiogenic shoc% after #"ocardial infarction2a.=P M D@, Pulse M 11irregular .=P M 0, P ulse M 0 re gular c.=P M 16 D, Pu lse M 1 r egular d.=P M 1D1, Pulse M ir regu la r 6.;hich is the #ost a''ro'riate nursing action in otaining a lood 'ressure#easure#ent2a.Ta%e the 'ro'er eui'#ent, 'lace theclient in a co#fortale'osition, and record the a''ro'riate infor#ation in the client&s chart..4easure the client&s ar#, if "ou are not sure of thesi)e of cuff touse.c.a!e the client recline or sit co#fortal" in a chair $ith the forear#at the le!el of the heart d.7ocu#ent the #easure#ent, $hich e*tre#it" $as used, and the'osition that the client $as in during the #easure#ent.61.As%ing the

uestions to deter#ine if the 'erson understands the healthteaching 'ro!ided " the nurse $ould e included during $hich ste' of thenursing 'rocess2a. Assess#ent .E!aluationc.I#'le#entationd . P l a n n i n g a n d g o a l s 6+.;hich of the follo$ing ite# is considered the single #ost i#'ortant factor in assisting the health'rofessional in arri!ing at a diagnosis or deter#ining the 'erson&s needs2a. 7i ag nos ti c te st re su lts . = i o g r a ' h i c a l d a t e c. is to r" of'resent il lnessd.Ph"sical e*a#ination66.In 're!enting the de!elo'#ent of an e*ternal rotation defor#it" of the hi'in a client $ho #ust re#ain in ed for an" 'eriod ofti#e, the #osta''ro'riate nursing action $ould e to use(a.Trochanter roll e*tending fro# the crest of the ileu# to the #id-thigh..Pillo$s

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un de r th e lo $e r le gs . c . F o o t o a r d d. i '- a du ct or 'i ll o$ 6:.;hich stage of 'ressure ulcer de!elo'#ent does the ulcer e*tend intothesucutaneous tissue2a . S t a g e I . S t a g e I I c . S t a g e I I I d . S t a g e I 3 60.;hen the #ethod of $ound healing is one in

$hich $ound edges are notsurgicall" a''ro*i#ated and integu#entar" continuit" is restored "granulations, the $ound healing is ter#eda. Secondintention healing.Pri#ar" intention healingc.Third intention healing d.First inte ntion [email protected] D-"ear-old #ale client is ad#itted to the hos'ital $ith a diagnosis of 'neu#onia. Nurse 5li!er learnsthat the client li!es alone and hasn&t eeneating or drin%ing. ;hen assessing hi# for deh"dration, nurse 5li!er $ould e*'ect to

find(a. " ' o t h e r # i a . " ' e r t e n s i o n c. 7i st en de d ne c% !e in sd . T a c h " c a r d i a 6B.The 'h"sician 'rescries #e'eridine>7e#erol?, B0 #g I.4. e!er" : hoursas needed, to control a client&s 'osto'erati!e 'ain. The 'ac%age insert is84e'eridine, 1 #g#l.9 o$ #an"#illiliters of #e'eridine should theclient recei!e2a . . B 0 . . @ c . . 0 d . . + 06D.

A #ale client $ithdiaetes #ellitusis recei!ing insulin. ;hich state#entcorrectl" descries an insulin unit2a.It&s a co##on #easure#ent in the#etric s"ste#..It&s the asis for solids in the a!oirdu'ois s"ste#.c.It&s the s#allest #easure#ent in the a'othecar"s"ste#.d.It&s a #easure of effect, not a standard #easure of $eight or uantit".6.Nurse 5li!er #easures a client&s te#'erature at 1+ F. ;hatis theeui!alent Centigrade te#'erature2a . : . 1 C . 6 D . C c . : D C d . 6 D C :.The nurse is assessing a :D-"ear-old client $ho has co#e to the'h"sician&s office for his annual 'h"sical e*a#. 5ne of the first 'h"sicalsigns of aging is(a.Acce'ting li#ita tion s

$hile de!elo'ing assets.. Increasing loss of #us cle tone.c.Failing e"esight, es'eciall " close !ision.

d.a!ing #ore freuent aches and 'ains.:1.The 'h"sician inserts a chest tue into a fe#ale client to treat a'neu#othora*. The tue isconnected to $ater-seal drainage. The nursein-charge can 're!ent chest tue air lea%s "(a.Chec%ing and ta'ing all connections..Chec%ing'atenc " of the chest tue.c .Hee'i ng the head of the ed slight l" e le!ated. d.Hee'ing the chest drainage s"ste# elo$ the le!el ofthe chest.:+.Nurse Trish #ust !erif" the client&s identit" efore ad#inistering#edication. She is a$are that the safest $a" to !erif" identit" isto(a.Chec% the client&s identific ation and..As% the client to state his na#e.c.State the client&s na#e out loud and $ait acl ient to re'eat it .d.Chec% the roo# nu#er and the client&s na#e on the ed.:6.The 'h"sician orders de*trose 0 in $ater, 1, #l to einfused o!er Dhours. The I.3. tuing deli!ers 10 dro's#l. Nurse Oohn should run the I.3.infusion at a rate of(a. 6 d r o ' s # i n u t e . 6 +d r o ' s # i n u t e c . + d r o ' s # i n u t e d . 1 D d r o ' s # i n u t e ::.If a central !enous catheter eco#es disconnected accidentall",

$hatshould the nurse in-charge do i##ediatel"2a. C l a # ' t h e c a t h e t e r . C a l l a n o t h e r n u r s e c . C a l l t h e ' h " s i c i a n d.A ''l" a

dr" steri le dres sing to the si te .:0.A fe#ale client $as recentl" ad#itted. She has fe!er, $eight loss, and$ater" diarrhea is eing ad#itted to thefacilit". ;hile assessing the client,Nurse a)el ins'ects the client&s ado#en and notice that it is slightl"conca!e. Additional assess#ent should 'roceedin $hich order(a.Pal'ation, auscultation, and 'ercussion..Percussion, 'al'ation, and auscultation.c.Pal'ation, 'ercussion,and auscultation.d.Auscultation, 'ercussion, and 'al'ation.:@. Nurse =ett" is assessing tactile fre#itus in a client $ith 'neu#onia. For this e*a#ination, nurse =ett" should usethe(a. F i n g e r t i ' s . F i n g e r ' a d s c.7orsal surface of the handd.Ulnar surface of the hand:B. ;hich t"'e of e!aluationoccurs continuousl" throughout the teaching andlearning 'rocess2a . S u # # a t i ! e . I n f o r # a t i ! e c . F o r # a t i ! e d . R e t r o s ' e c t i ! e :D.A :0 "ear old client, has no fa#il" histor" of reast canceror other ris%factors for this disease. Nurse Oohn should instruct her to ha!e#a##ogra# ho$ often2a . T $ i c e ' e r " e a r . 5 n c e ' e r

" e a r c . E ! e r " + " e a r s d. 5nce, to estali sh a seline:.A #ale client has the follo$ing arterial lood gas !alues( ' B.6 Pao+D##g Paco+ 0 ##g and C56 +@#EJ. =ased on these !alues,Nurse Patricia should e*'ect $hich condition2a.Res'irator"aci dos is .Re s'i rat or" al% alos is c. 4e ta ol i c ac id o s i sd .4 e ta ol ic al %a lo si s 0.Nurse Jen refers a fe#ale client $ith ter#inal

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cancer to a local hos'ice.;hat is the goal of this referral2a.To hel' the cl ient find a''ro'riate treat#ent o'tions. .To 'ro!ide su''ortfor the client and fa#il" in co'ing $ith ter#inalillness.c.To ensure that the client gets counseling regarding health carecosts.d.To teachthe client and fa#il" aout cancer and its treat#ent. 01.;hen caring for a #ale client $ith a 6-c# stage I 'ressure ulcer on thecocc"*, $hich of the follo$ing actions can the nurse instituteinde'endentl"2a.4assaging the area $ith an astringent e!er" + hours..A''l"ing an antiiotic crea# to the area three ti#es 'er da".c.Usingnor#al saline solution to clean the ulcer and a''l"ing a'rotecti!e dressing as necessar".d.Using a 'o!idone-iodine $ash on the ulceration

three ti#es 'er da".0+.Nurse 5li!er #ust a''l" an elastic andage to a client&s an%le and calf. eshould a''l" the andage eginning at theclient&s(a . H n e e . A n % l e c . J o $ e r t h i g h d . F o o t 06.A 1 "ear old child $ith t"'e 1 diaetes de!elo's diaetic%etoacidosisand recei!es a continuous insulin infusion. ;hich condition re'resents thegreatest ris% to this child2a. " 'e rn at re #i a . " ' o % a l e # i a c. " 'e r' ho s' ha te #i ad . " ' e r c a l c e # i a 0:.Nurse Jen is ad#inistering sulingualnitrgl"cerin >Nitrostat? to the ne$l"ad#itted client. I##ediatel" after$ard, the client #a" e*'erience(a.Thro in g head ache ordi))iness.Ner !ou sne ss or 'ar est hes ia. c.7 ro$ sin ess or lu rre d ! isi on. d.Ti nni tus or di' lo' ia. 00.Nurse 4ichelle hearsthe alar# sound on the tele#etr" #onitor. The nurseuic%l" loo%s at the #onitor and notes that a client is in a !entricular tach"cardia. The nurse rushesto the client&s roo#. U'on reaching theclient&s edside, the nurse $ould ta%e $hich action first2a. Pre'are for cardio!ersion .Pre'are todefirillate the clientc . C a l l a c o d e d.Chec% the client&s le!el of consciousness

[email protected] a)el is 're'aring to a#ulate a fe#ale client. The est and thesafest 'osition for the nurse in assisting the client is to stand(a.5n theunaffected side of the client..5n the affected side of the client.c. In f ro nt of th e cl ie nt .d .= eh in d th e cl ie nt . 0B.NurseOanah is #onitoring the ongoing care gi!en to the 'otential organdonor $ho has een diagnosed $ith rain death. The nurse deter#inesthat thestandard of care had een #aintained if $hich of the follo$ingdata is oser!ed2a. Urine out' ut ( :0 #l hr .C a'illar" refi l l ( 0s econ d s c . S eru # '( B . 6+d . =l ood 'res s u re( :D # # g0D.Nurse A#" has an order to otain aurinal"sisfro# a #ale client $ith anind$elling urinar" catheter. The nurse a!oids $hich of the follo$ing,

$hichconta#inate the s'eci#en2a.;i'ing the 'ort $ith an alcohol s$a efore inserting the s"ringe..As'irating a s a#' le fro# the'ort on the drainage ag.c.Cla#'ing the tuing of the drainage ag.d.5taining the s'eci#en fro# the urinar" drainage

ag.0.Nurse 4eredith is in the 'rocess of gi!ing a client a ed ath. In the#iddle of the 'rocedure, the unit secretar" calls the nurse on the

interco#to tell the nurse that there is an e#ergenc" 'hone call. The a''ro'riatenursing action is to(a.I##ediatel" $al% out of the client&s roo#and ans$er the 'honecall..Co!er the client, 'lace the call light $ithin reach, and ans$er the'hone call.c.Finish the ed ath eforeans$ering the 'hone call.d.Jea!e the client&s door o'en so the client can e #onitored and thenurse can ans$er the 'hone call.@. NurseOanah is collecting a s'utu# s'eci#en for culture and sensiti!it"testing fro# a client $ho has a 'roducti!e cough. Nurse Oanah 'lans toi#'le#ent $hichinter!ention to otain the s'eci#en2a.As% the client to e*'ectorate a s#all a#ount of s'utu# into thee#esis asin.

.A s% the cl ient to otai n the s'eci#e n a fter rea%fast.c .Use a s teri le 'lastic container for otaining thes'eci#en.d.Pro!ide tissues for e*'ectoration and otaining the s'eci#en.@1. Nurse Ron is oser!ing a #ale client using a $al%er. Thenursedeter#ines that the client is using the $al%er correctl" if the client(a.Puts all the four 'oints of the $al%er flat on the floor, 'uts $eightonthe hand 'ieces, and then $al%s into it..Puts $eight on the hand 'ieces, #o!es the $al%er for$ard, andthen $al%s into it.c.Puts $eight onthe hand 'ieces, slides the $al%er for$ard, and then$al%s into it.d.;al%s into the $al%er, 'uts $eight on the hand 'ieces, and then'uts allfour 'oints of the $al%er flat on the floor.@+.Nurse A#" has docu#ented an entr" regarding client care in the client&s#edical record. ;hen chec%ing the

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entr", the nurse reali)es that incorrectinfor#ation $as docu#ented. o$ does the nurse correct this error2a.Erases the error and $rites in thecorrect infor#ati on..Uses correction fluid to co!er u' the incorrect infor#ation and$rites in the correct infor#ation.c.7ra$s one lineto cross out the incorrect infor#ation and theninitials the change.d.Co!ers u' the incorrect infor#ation co#'letel" using a lac%'enand $rites in the correct infor#[email protected] Ron is assisting $ith transferring a client fro# the o'erating roo#tale to a stretcher. To 'ro!idesafet" to the client, the nurse should(a.4o!es the client ra'idl" fro# the tale to the stretcher..Unco!ers the client co#'letel" eforetransferring to the stretcher.c.Secures the client safet" elts after transferring to the stretcher.d.Instructs the client to #o!e self fro# thetale to the stretcher.@:.Nurse 4"rna is 'ro!iding instructions to a nursing assistant assigned togi!e a ed ath to a client $ho is on contact

'recautions. Nurse 4"rnainstructs the nursing assistant to use $hich of the follo$ing 'rotecti!eite#s $hen gi!ing ed ath2a . G o $ n a n dgoggl es . Go$ n a n d g l o!es c . Gl o!es a n d s hoe 'rotectors d . Gl o!es a n d goggl es @0. Nurse 5li!er is caring for a client $ith i#'aired #oilit" that occurred as aresult of a stro%e. The client has right sided ar# and leg $ea%ness.Thenurse $ould suggest that the client use $hich of the follo$ing assisti!ede!ices that $ould 'ro!ide the est stailit" for a#ulating2a . C r u t c h e s .Single straigh t-legged c anec . u a d c a n e d . ; a l % e r @@.A #ale client $ith a right 'leural effusion notedon a chest L-ra" is eing're'ared for thoracentesis. The client e*'eriences se!ere di))iness $hensitting u'right. To 'ro!ide a safe en!iron#ent, the nurseassists the clientto $hich 'osition for the 'rocedure2a.Prone $ith head turned to$ard the side su''orted " a 'illo$..Si#s& 'osi tion $iththe head of the ed flat.c.Right side-l"ing $ith the head of the ed ele!ated :0 degrees.d.Jeft side-l"ing $ith the head of the edele!ated :0 [email protected] Oohn de!elo's #ethods for data gathering. ;hich of the follo$ingcriteria of a good instru#ent refers to the ailit" of the

instru#ent to "ieldthe sa#e results u'on its re'eated ad#inistration2a . 3 a l i d i t " . S ' e c i f i c i t " c . S e n s i t i ! i t " d . R e l i a i l i t " @D.arr" %no$s that he has to 'rotect the rights of hu#an researchsu


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sti'ulated in RA 1B6d.;ill re#ain unale to 'ractice 'rofessional nursingBB.Ronald 'lans to conduct a research on the use of a ne$#ethod of 'ainassess#ent scale. ;hich of the follo$ing is the second ste' in theconce'tuali)ing 'hase of the research 'rocess2a.For#ul at ing th eresearch h"'othesis.Re !ie $ rel ate d lit era tur ec.For#ulating and deli#iting the research 'role#d.7esign thetheoretical and conce'tual fra#e$or% BD.The leader of the stud" %no$s that certain 'atients $ho are in as'eciali)ed research setting tend to res'ond 's"chologicall" to theconditions of the stud".This referred to as (a.C au se an d ef fe c t . a$ th o rn e ef fe ct c . a l o e f f e c t d . o r n s e f f e c t B.4ar" finall" decides to use


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nursing inter!ention ta%es highest 'riorit" $hen caring for a ne$l"ad#itted client $hoKs recei!ing a lood transfusion2a.Instructing the client tore'ort an" itching, s$elling, or d"s'nea..Infor#ing the client that the transfusion usuall" ta%e 1 Q to + hours.c.7ocu#enting loodad# inistration in the client care record.d.Assessing the client&s !ital signs $hen the transfusion ends.:.A #ale client co#'lains ofado#inal disco#fort and nausea $hilerecei!ing tue feedings. ;hich inter!ention is #ost a''ro'riate for this'role#2a.Gi!e the feedi ngs atroo# te#'erature..7ecrease the rate of feedings and the concentration of the for#ula.c.Place the client in se#i-Fo$lerKs'osition $hile feeding.d.Change the feeding conta iner e!er" 1+ hours. 0.Nurse Patricia is reconstituting a 'o$dered #edication in a

!ial. After adding the solution to the 'o$der, she nurse should(a . 7 o n o t h i n g . .In!ert the !ial and l et it sta nd for 6 to 0

#inutes.c.Sha%e the !ial !igorousl".d.Roll the !ial gentl" et$een the 'al#s.@.;hich inter!ention should the nurse Trish use $hen ad#inistering o*"gen" face #as% to a fe#ale client2a.Secure the elastic and tightl" around the clientKs head..Assist the client to these#i-Fo$ler 'osition if 'ossile.c.A''l" the fa ce #a s% fro# the client Ks chin u' o!er the no se. d.Joosen the connectors et$een the o*"gen eui'#ent andhu#idifier.B.The #a*i#u# transfusion ti#e for a unit of 'ac%ed red lood cells>R=Cs?is(a . @ h o u r s . : h o u r s c . 6 h o u r s d . + h o u r s D.Nurse 4oniue is #onitoring the effecti!eness of a clientKsdrug thera'".;hen should the nurse 4oniue otain a lood sa#'le to #easure thetrough drug le!el2a.1 hour efore ad#inistering the ne*tdose..I##ediatel" efore ad#inistering the ne*t dose.c.I##ediatel" after ad#inistering the ne*t dose.d.6 #inutesafter ad#inister ing the ne*t dose..Nurse 4a" is a$are that the #ain ad!antage of using a floor stoc% s"ste#is(a.The nurse cani#'le#ent #edication orders uic%l"..The nurse recei!es in'ut fro# the 'har#acist.c.The s"ste# #ini#i)es

transc ri'tion errors.d.The s"ste# reinf orces accura te calcul ations .1.Nurse 5li!er is assessing a clientKs ado#en. ;hichfinding should thenurse re'ort as anor#al2a.7 ul ln es s o! er th e li !e r. .=o$el sounds occurring e!er" 1 s econds .c.Shi ftingdullness o!er the ado#en.d.3ascular sounds heard o!er the r enal arteries TEST II - Co##unit" ealth Nursing and Care of the 4other and Child1.4a" arri!es at the health care clinic and tells the nurse that her last#enstrual 'eriod $as $ee%s ago. She also tells the nurse that aho#e'regnanc" test $as 'ositi!e ut she egan to ha!e #ild cra#'s and isno$ ha!ing #oderate !aginal leeding. 7uring the 'h"sical e*a#inationof the client, the nurse notes that 4a" has a dilated cer!i*. The nursedeter#ines that 4a" is e*'eriencing $hich t"'e of aortion2a . I n e ! i t a l e . I n c o # ' l e t e c . T h r e a t e n e d d . S e ' t i c +.Nurse Reese is re!ie$ing the record of a 'regnant client forher first'renatal !isit. ;hich of the follo$ing data, if noted on the client&s record,$ould alert the nurse that the client is at ris% for a s'ontaneousaortion2a . A g e 6 @ " e a r s . ist or " of s"' hi l is c.istor" of genital her'esd.istor" of diaetes #el l itus6.Nursea)el is 're'aring to care for a client $ho is ne$l" ad#itted to thehos'ital $ith a 'ossile diagnosis of ecto'ic 'regnanc". Nurse a)elde!elo's a'lan of care for the client and deter#ines that $hich of thefollo$ing nursing actions is the 'riorit"2a. 4 o n i t o r i n g $ e i g h t . A s s e s s i n g f o re d e # a c. 4on it or in g a' ic al 'u ls ed .4 on it or in g te #' er atu re :.Nurse 5li!er is teaching a diaetic 'regnant client aoutnutrition andinsulin needs during 'regnanc". The nurse deter#ines that the clientunderstands dietar" and insulin needs if the client states that thesecondhalf of 'regnanc" reuire(a.7ecreased caloric inta%e.Increased caloric inta%ec.7ecreased Insulind.IncreaseI n s u l i n0.Nurse 4ichelle is assessing a +: "ear old client $ith a diagnosis of h"datidifor# #ole. She is a$are that one of the follo$ing isunassociated$ith this condition2a.E*cessi!e fetal acti!it"..Jarger than nor#al uterus for gestational age.c.3aginal

l e e d i n g d.Ele!ated le!els of hu# an chorionic gonadotro'in. @.A 'regnant client is recei!ing #agnesiu# sulfate for se!ere'regnanc"induced h"'ertension >PI?. The clinical findings that $ould $arrant use of the antidote , calciu# gluconate is(a .Urinar" out'ut cc i n + ho urs..A sent 'atel lar re fle*e s.c.Ra'id res'irator" rate ao!e :#in.d.Ra'id rise in lo od


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'ressure.B.7uring !aginal e*a#ination of Oanah $ho is in laor, the 'resenting 'art isat station 'lus t$o. Nurse, correctl" inter'rets itas(a.Presenting 'art is + c# ao!e the 'lane of the ischial s'ines..=i'arietal dia#eter is at the le!el of the ischials'ines.c.Presenting 'art in + c# elo$ the 'lane of the ischial s'ines.d.=i'arietal dia#eter is + c# ao!e the ischials'ines.D.A 'regnant client is recei!ing o*"tocin >Pitocin? for induction of laor. Acondition that $arrant the nurse in-charge to discontinueI.3. infusion of Pitocin is(a.Contractions e!er" 1 Q #inutes lasting B-D seconds..4aternal te#'erature 11.+c.Earl"decel eratio ns in the fetal heart rate.d .Fetal heart rate aseline 1 :-1@ '#. .Calciu# gluconate is eing ad#inistered to aclient $ith 'regnanc"induced h"'ertension >PI?. A nursing action that #ust e initiated as the'lan of care throughout in


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ser!ices.c.Co##unit" health nursing is intended 'ri#aril" for health 'ro#otionand 're!ention and treat#ent of disease.d.The goal ofco##unit" health nursing is to 'ro!ide nursing ser!icesto 'eo'le in their o$n 'laces of residence.++.Nurse Tina is a$are that the disease declaredthrough PresidentialProcla#ation No. : as a target for eradication in the Phili''ines is2a . P o l i o # " e l i t i s . 4 e a s l e s c . R a i e s d .N e o n a t a l t e t a n u s +6.4a" %no$s that the ste' in co##unit" organi)ing that in!ol!es training of 'otential leaders in the co##unit"is(a. I n t e g r a t i o n . Co##un it" organ i)ati onc . Co ## un it " st ud "d . Core grou' for#a tion +:.=eth a 'ulic health nurseta%es an acti!e role in co##unit" 'artici'ation.;hat is the 'ri#ar" goal of co##unit" organi)ing2a.To educate the 'eo'le regarding co##unit"health 'role#s.To #oili)e the 'eo'le to resol!e co##unit" health 'role#sc.To #a*i#i)e the co##unit"&s resources in dealing

$ith health'role#s.d.To #a*i#i)e the co##unit"&s resources in dealing $ith health'role#s. +0.Tertiar" 're!ention is needed in $hich stage of the natural histor" of disease2a . P r e -' a t h o g e n e s i s . P a t h o g e n e s i s c . P r o d r o # a l d . T e r # i n a l [email protected] nurse is caring for a 'ri#igra!id client in the laor anddeli!er" area.;hich condition $ould 'lace the client at ris% for disse#inatedintra!ascular coagulation >7IC?2a.Intrauterine fetaldeath..Pla ce nta acc ret a.c .7" sf unc tio nal la or . d.Pre#ature ru'ture of the #e#ranes.+B.A fullter# client is in laor.Nurse =ett" is a$are that the fetal heart rate$ould e(a. D to 1 e at s #i nu te . 1 to 1+ e at s #i nu te c. 1+ to 1@

eats#i nuted.1 @ to 1D eats#i nute +D.The s%in in the dia'er area of a B #onth old infant is e*coriated and red.Nurse a)el shouldinstruct the #other to(a.C ha ng e th e di a' er #o re of te n. .A''l" talc 'o$der $ith dia'er changes.c.;ash the area !igorousl"

$ith each dia'er chang e.d.7ecrease the infant&s fluid inta%e to decrease saturating dia'ers.+.Nurse Carla %no$s that the co##on cardiac

ano#alies in children $ith7o$n S"ndro#e >tri-so#" +1? is(a. At ri al se 't al de fe ct . P u l # o n i c s t e n o s i s c. 3e nt ri cu la r se 't aldefectd.Endocardial cushion defect6.4alou $as diagnosed $ith se!ere 'reecla#'sia is no$ recei!ing I.3.#agnesiu# sulfate. The ad!erseeffects associated $ith #agnesiu#sulfate is(a . A n e # i a

.7 ecreas ed ur ine out'utc . " ' e r r e f l e * i a d.I ncreased res'irato r" rate 61.A +6 "ear old client is ha!ing her #enstrual 'eriode!er" + $ee%s that lastfor 1 $ee%. This t"'e of #enstrual 'attern is ets defined

"(a . 4 e n o r r h a g i a . 4 e t r o r r h a g i a c . 7 " s ' a r e u n i a d . A # e n o r r h e a 6+.Oannah is ad#itted to the laor and deli!er" unit.The critical laorator"result for this client $ould e(a. 5 *" g en sa tu r at i o n .Ir on in din g ca' aci t"c . = l o o d t " ' i n g d . S e r u #C a l c i u # 66.Nurse Gina is a$are that the #ost co##on condition found during thesecond-tri#ester of 'regnanc" is(a. 4 e t a o l i cal %a lo si s .Res' irato r" acido sisc . 4 a s t i t i s d. Ph "s io lo gi c an e# ia 6:.Nurse J"nette is $or%ing in the triage area of ane#ergenc" de'art#ent.She sees that se!eral 'ediatric clients arri!e si#ultaneousl". The client$ho needs to e treated first is(a. A cr"ing 0 "ear oldchi ld $ith a laceration on his scal '. .A : "ear old child $ith a ar%ing coughs and flushed a''earance.c.A 6 "ear old child $ith7o$n s"ndro#e $ho is 'ale and aslee' inhis #other&s ar#s.d.A + "ear old infant $ith stridorous reath sounds, sitting u' in his#other&sar#s and drooling.60.4aureen in her third tri#ester arri!es at the e#ergenc" roo# $ith 'ainless!aginal leeding. ;hich of the follo$ing conditions issus'ected2a.P lac ent a 'r e! ia .A ru' tio 'l ace nta e c .P r e #a tu r e l a o r d.Se*uall" trans#itted disease [email protected] "oung child na#ed Richard is sus'ected of ha!ing 'in$or#s. Theco##unit" nurse collects a stool s'eci#en to confir# the diagnosis. Thenurseshould schedule the collection of this s'eci#en for(a. O u s t e f o r e e d t i # e .A ft er th e ch il d ha s e en a th e c . A n " t i # e d u r i n gt h e d a " d . E a r l " i n t h e # o r n i n g 6B.In doing a child&s ad#ission assess#ent, Nurse =ett" should e alert tonote $hich signs or s"#'to#s ofchronic lead 'oisoning2a.Irr ita il it" and sei )ure s. 7eh "dr ati on and dia rrh eac .=r ad" car dia andh"'otensiond.Petechiae and he#aturia 6D.To e!aluate a $o#an&s understanding aout the use of dia'hrag# for fa#il" 'lanning, NurseTrish as%s her to e*'lain ho$ she $ill use thea''liance. ;hich res'onse indicates a need for further health teaching2a.8I should chec% the dia'hrag#


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carefull" for holes e!er" ti#e I use it9.8I #a" need a different si)e of dia'hrag# if I gain or lose $eight#ore than + 'ounds9c.8Thedia'hrag# #ust e left in ' lace for atle ast @ hours afte r intercourse9d.8I reall" need to use the dia'hrag# and


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.Cholerac.

A#eiasis

d . 7 " s e n t e r " 01.The #ost 're!alent for# of #eningitis a#ong children aged + #onths to 6"ears is caused " $hich#icroorganis#2 a.e#o'hilus influen)ae . 4 o r i l l i ! i r u s c. Ste'toc occus ' neu#oniaed. Neisse ria

#eningitidis0+.The student nurse is a$are that the 'athogno#onic sign of #easles isHo'li%&s s'ot and "ou #a" see Ho'li%&s s'ot " ins'ectingthe(a. Na s a l #u c o s a . =u c c a l #u c o s a c.S %in on the ad o#e nd . S % i n o n n e c % 06.Angel $as diagnosed as ha!ing7engue fe!er. ou $ill sa" that there isslo$ ca'illar" refill $hen the color of the nailed that "ou 'ressed does notreturn $ithin ho$ #an" seconds2a . 6s e c o n d s . @ s e c o n d s c . s e c o n d s d . 1 s e c o n d s 0:.In Integrated 4anage#ent of Childhood Illness, the nurse is a$arethatthe se!ere conditions generall" reuire urgent referral to a hos'ital. ;hichof the follo$ing se!ere conditions 75ES N5T al$a"s reuireurgentreferral to a hos'ital2a . 4 a s t o i d i t i s . Se !e re de h" dr at io nc .S e! er e 'n eu #o ni a d.Se!e re feri le d iseas e00.4"rnaa 'ulic health nurse $ill conduct outreach i##uni)ation in aaranga" 4asa" $ith a 'o'ulation of aout 10. The esti#ated nu#er of infants in the

aranga" $ould e(a . : 0 i n f a n t s . 0 i n f a n t s c . 0 0 i n f a n t s d . @ 0 i n f a n t [email protected] co##unit" nurse is a$are that the iological used in E*'andedProgra# on I##uni)ation >EPI? should N5T e stored in the free)er2a . 7 P T . 5 r a l ' o l i o ! a c c i n e c . 4 e a s l e s ! a c c i n e d . 4 4 R 0B.It is the #ost effecti!e $a" of controlling

schistoso#iasis in an ende#icarea2a.Use of #ol lusc ici des .= uil din g o f foo t rid ges c.P ro' er use of san ita r"toiletsd.Use of 'rotecti!e foot$ear, such as ruer oots0D.Se!eral clients is ne$l" ad#itted and diagnosed $ith le'ros". ;hich ofthefollo$ing clients should e classified as a case of #ultiacillar" le'ros"2a.6 s%in lesions, negati!e slit s%in s#ear .6 s%in lesions,'ositi!e slit s%in s#ear c.0 s%in lesions, negati!e slit s%in s#ear d.0 s%in lesions, 'ositi!e slit s%in s#ear 0.Nurses are a$arethat diagnosis of le'ros" is highl" de'endent onrecognition of s"#'to#s. ;hich of the follo$ing is an earl" sign of le'ros"2a . 4 a c u l a rl es i o ns .In ai lit " t o c los e e "el ids c.T hic %en ed 'ai nfu l n er! esd .Si n%i ng of the nos er idg e @.4arie rought her 1 #onthold infant for consultation ecause of fe!er,started : da"s 'rior to consultation. In deter#ining #alaria ris%, $hat $ill"ou do2a.Perfor# atourniuet test..As% $here the fa#il" resides.c.Get a s'eci#en for lood s#ear.d.As% if the fe!er is 'resente!er"d a"[email protected] rought her : "ears old daughter to the RU ecause of cough andcolds. Follo$ing the I4CI assess#ent guide, $hich of thefollo$ing is adanger sign that indicates the need for urgent referral to a hos'ital2 a .I na il it" to dri n% .i gh gra de fe !e r c.Signs of se!ere deh"drationd.Cough for #ore than 6 da"s@+.Oi##" a+-"ear old child re!ealed 8agg" 'ants9. As a nurse, using theI4CI guidelines, ho$ $ill "ou #anage Oi##"2a.Refer the chi ld urge ntl" to ahos'ital for confine#ent..Coordinate $ith the social $or%er to enroll the child in a feeding'rogra#.c.4a%e a teaching 'lan for the#other, focusing on #enu 'lanning for her child.d. Assess and treat the child for health 'role#s li%e infections andintestinal'arasitis#[email protected] is using 5resol in the #anage#ent of diarrhea of her 6-"ear oldchild. She as%ed "ou $hat to do if her child !o#its. As anurse "ou $ill tellher to( a.=ring the child to the nearest hos'ital for further assess#ent..=ring the child to the health center forintra!enous fluid thera'".c.=ring the child to the health center for assess#ent " the 'h"sician.d.Jet the child rest for 1 #inutes thencontinue gi!ing 5resol #oreslo$l".@:.Ni%%i a 0-#onth old infant $as rought " his #other to the health center ecause of diarrhea for : to 0 ti#esa da". er s%in goes ac% slo$l" after a s%in 'inch and her e"es are sun%en. Using the I4CI guidelines, "ou $illclassif" this infant in $hich categor"2a.No signs of deh"dration . So #e de h" dr at io nc .S e! er e de h" dr at io n d. The data is [email protected] a :-#onth

http://nursingcrib.com/cholera-el-tor/http://nursingcrib.com/amoebiasis-amebiasis-amoebic-dysentery-case-study/http://nursingcrib.com/cholera-el-tor/http://nursingcrib.com/amoebiasis-amebiasis-amoebic-dysentery-case-study/


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"'ergl"ce#ia due to decreased gl"cogen storesd.Pol"c"the#ia 'roal" due to chronic fetal h"'o*iaB6.4ar


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a.Si#ian crease .Con%egel?e*ercises.D1. A 'regnant $o#an acco#'anied " her husand, see%s ad#ission to thelaor and deli!er" area. She

states that sheKs in laor and sa"s she attended thefacilit" clinic for 'renatal care. ;hich uestion should the nurse 5li!er as% her first2a .87o "ou ha!ean" chronic illnesses29.8 7o "ou ha! e an" all erg ies 29 c.8;hat is "our e*'ected due date29d.8;ho $ill e $ith "oudur ing la or29 D+.A neonate egins to gag and turns a dus%" color. ;hat should the nursedo first2 a. C al # th e n eo n at e . .No tif " the 'h" sic ian .c.Pro!ide o*"gen !ia face #as% as orderedd.As'irate the neonate&s nose and#outh $ith a ul s"ringe.D6.

;hen a client states that her $ater ro%e, $hich of the follo$ing actions$ould e ina''ro'riate for the nurse to do2a.5ser!ing the 'ooling ofstra$- colored fluid. .Chec%ing !agina l discha rge $ith nitra) ine 'a'er .c.Conducting a edside ultrasound for an a#niotic fluidinde*.d.5ser!ing for fla%es of !erni* in the !aginal discharge. D:. A a" girl is orn D $ee%s 're#ature. At irth, she has nos'ontaneousres'irations ut is successfull" resuscitated. ;ithin se!eral hours she de!elo'sres'irator" grunting, c"anosis, tach"'nea, nasal flaring, andretractions. SheKsdiagnosed $ith res'irator" distress s"ndro#e, intuated, and 'laced on a!entilator. ;hich nursing action should e included in the

a"Ks 'lan of care to're!ent retino'ath" of 're#aturit"2a.Co!er his e"es $hi le recei!ing o*"gen..Hee' her od" te#'eratu relo$.c.4onitor 'artial 'ressure of o*"gen >Pao+? le!els.d.u#idif" the o*"gen.D0. ;hich of the follo$ing is nor#al ne$orncalorie inta%e2a.11 to 16 cal ori es 'e r % g. .6 to : calories 'er l of od" $eight.c.A t l eas t + #l 'er fee din gd. to1 calories 'er %gD@. Nurse Oohn is %no$ledgeale that usuall" indi!idual t$ins $ill gro$a''ro'riatel" and at the sa#e rate as singletons untilho$ #an" $ee%s2a . 1 @ to 1 D $ e e% s . 1 D to + + $ e e %s c . 6 t o 6 + $ e e % s d . 6D to : $ e e% s DB. ;hich of thefollo$ing classifications a''lies to #ono)"gotic t$ins for $ho#the clea!age of the fertili)ed o!u# occurs #ore than 16 da"s after fertili)ation2a.con


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a . A # n i o c e n t e s i s .7igital or s'eculu# e*a#inationc.E*ternal fetal #onitoringd . U l t r a s o u n d D. Nurse Arnold %no$sthat the follo$ing changes in res'irator" functioningduring 'regnanc" is considered nor#al(a. Increased tidal !olu#e.Increasede* 'ir at or " !o lu #e c.7ecreased ins' irator" ca'acit"d.7ecrea sed o*"gen consu#'tion. E#il" has gestational diaetes and it isusuall" #anaged " $hich of thefollo$ing thera'"2a . 7 i e t .Jo ng- act ing ins uli nc .5 r al h "' o gl "c e #i c d.5ral h"'ogl"ce#icdrug an d insuli n1. 4agnesiu# sulfate is gi!en to Oe##a $ith 'reecla#'sia to 're!ent $hich of the follo$ing condition2a . e # o r r h a g e ."'ertensionc . " ' o # a g n e s e # i a d .Sei)ure+. Ca##ile $ith sic%le cell ane#ia has an increased ris% for ha!ing a sic%lecellcrisis during 'regnanc". Aggressi!e #anage#ent of a sic%le cell crisis includes$hich of the follo$ing #easures2a.Antih"'ertensi!e

agents.7iu re t ic age nts c . I . 3 . f l u i d s d.Aceta#ino'hen >T"lenol? for 'ain 6. ;hich of the follo$ing drugs is the antidote for #agnesiu# to*icit"2a.Calciu# gluconate >Halcinate?."drala)ine>A 'r es ol in e? c . N a l o * o n e > N a r c a n ? d.Rho >7? i##une gloulin >RhoGA4?:. 4arl"n is screened for tuerculosis during her first'renatal !isit. Anintrader#al inPP7? of the tuerculin acilli isgi!en. She is considered to ha!e a 'ositi!e test for

$hich of the follo$ing results2a.An indurated $heal under 1 ## in dia#eter a''ears in @ to 1+ hours..An indurated $heal o!er 1 ##in dia#eter a''ears in :D to B+ hours.c.A flat circu#cised area under 1 ## in dia#eter a''ears in @ to 1+hours.d.A flat circu#cisedarea o!er 1 ## in dia#eter a''ears in :D to B+hours.0. 7ianne, +: "ear-old is +B $ee%s& 'regnant arri!es at her 'h"sician&s office$ithco#'laints of fe!er, nausea, !o#iting, #alaise, unilateral flan% 'ain, andcosto!erteral angle tenderness. ;hich of the follo$ing diagnoses is #ost li%el"2a.As"#'to#atic acteriuria.=acterial !aginosisc.P"elone'hritisd.Urinar " tract infection >UTI? @. Rh isoi##uni)ation in a

'regnant client de!elo's during $hich of thefollo$ing conditions2a.Rh-'ositi!e #aternal lood crosses into fetal lood, sti#ulatingfetalantiodies..Rh-'ositi!e fetal lood crosses into #aternal lood, sti#ulating#aternal antiodies.c.Rh-negati!e fetal lood crosses into#aternal lood, sti#ulating#aternal antiodies.d.Rh-negati!e #aternal lood crosses into fetal lood, sti#ulating fetalantiodies.B. To'ro#ote co#fort during laor, the nurse Oohn ad!ises a client to assu#ecertain 'ositions and a!oid others. ;hich 'osition #a" cause#aternalh"'otension and fetal h"'o*ia2a.J at er al 'o si ti on . S ua tt in g 'o si ti on c . S u ' i n e ' o s i t i o n d . S t a n d i n g ' o s i t i o n D. Celeste $ho used heroin during her 'regnanc" deli!ers a neonate. ;henassessing the neonate, the nurse Jh"nnettee*'ects to find(a.J et ha rg " + da" s af te r i rt h. .Irritailit" and 'oor suc%ing.c.A flattened nose , s#all e"es, and thinli's .d.Congenital defects such as li# ano#alies. . The uterus returns to the 'el!ic ca!it" in $hich of the follo$ing ti#e fra#es2a.Bthto thda" 'ost'artu#.. + $e e %s ' o st ' ar tu #.c.End of @th

$ee% 'ost'artu#.d.;hen the lochia changes to al a. 1. 4aureen, a 'ri#igra!ida client, age +, has


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TEST III - Care of Clients $ith Ph"siologic and Ps"chosocial Alterations1.Nurse 4ichelle should %no$ that the drainage is nor#al : da"s after asig#oid colosto#" $hen the stool is(a . G r e e n l i u i d . S o l i df o r # e d c . J o o s e , l o o d " d . S e # i f o r # e d +.;here $ould nurse Hristine 'lace the call light for a #ale client $ith aright-sided

rain attac% and left ho#on"#ous he#iano'sia2a.5n the cli ent& s r ight side . 5n th e client &s le ft sidec.7 irect l" in front of theclientd .;here the client l i%e 6.A #ale client is ad#itted to the e#ergenc" de'art#ent follo$ing anaccident. ;hat are the first nursing

actions of the nurse2a.Chec% res'iration, circulation, neurological res'onse..Align the s'ine, chec% 'u'ils, and chec% forhe#orrhage.c.Chec% res'irations, staili)e s'ine, and chec% circulation.d.Assess le!el of consciousness andcirculation.:.In e!aluating the effect of nitrogl"cerin, Nurse Arthur should %no$ that itreduces 'reload and relie!es angina

"(a.Increasing contract il it" and slo$i ng heart rate..Increasing A3 conduction a nd heart r ate .c.7e creasing contractil it"and o*"gen consu#'tion.d. 7ecreasing !enous return through !asodi lation .0.Nurse Patricia finds a fe#ale client $ho is 'ost-#"ocardial infarction >4I?slu#'ed on the side rails of the ed and unres'onsi!e to sha%ing or shouting. ;hich is the nurse ne*t action2a.Cal l forhel' and note the ti#e.. C le ar th e ai r $ a" c.Gi!e t$o shar' thu#'s to the 'recordiu#, and chec% the'ulse.d. Ad #i ni st er t$ o ui c% l o$s . @.Nurse 4onett is caring for a client reco!ering fro# gastro-intestinalleeding. The nurseshould(

a.Plan care so the client can recei!e D hours of uninterru'ted slee'each night..4onitor !ital signs e!er" + hours.c.4a%e sure that theclient ta%es food and #edications at 'rescriedinter!als.d.Pro!ide #il% e!er" + to 6 hours.B.A #ale client $as on $arfarin>Cou#adin? efore ad#ission, and haseen recei!ing he'arin I.3. for + da"s. The 'artial thro#o'lastin ti#e>PTT? is @D seconds. ;hat shouldNurse Carla do2a.Sto' the I.3. infusion of he'arin and notif" the 'h"sician..Continue treat#ent as ordered.c.E*' ect the $arfarinto increase the PTT.d.Increase the dosage, ecause the le!el is lo$er than nor#al.D.A client undergone ileosto#", $hen should thedrainage a''liance ea''lied to the sto#a2a.+: hou rs la ter, $hen ede#a has s usided . .I n th e o' er at in g ro o# .c .After theileos to#" egin to function.d.;hen the clien t is ale to egin s elf-care 'roced ures. .A client undergone s'inal anesthetic, it

$ill e i#'ortant that the nursei##ediatel" 'osition the client in(a.5n the side, to 're!ent ostruction of air$a" " tongue. . F l a t o n a c % . c.5n the ac %, $ith %nees fle*ed 10 degrees.d.Flat o n the sto#ach, $ith the head turned to the side. 1.;hile#onitoring a #ale client se!eral hours after a #otor !ehicleaccident, $hich assess#ent data suggest increasing intracranial'ressure2a.=lood'ressure is decrea sed fro# 1@ to 11B..Pulse is increased fro# DB to 0, $ith an occasional s%i''ed eat.c.The client isoriented $hen aroused fro# slee', and goes ac% toslee' i##ediatel".d.The client refuses dinner ecause of anore*ia.11.4rs. Cru),D "ears old is diagnosed $ith 'neu#onia. ;hich of thefollo$ing s"#'to#s #a" a''ear first2a.Altered #ental status and deh"dration

. F e ! e r a n d c h i l l s c.e#o 't"sis and 7"s'ne a d.Pleurit ic chest 'ain and cough1+. A #ale client has acti!e tuerculosis >T=?. ;hich of the follo$ing s"#'to#s$ill e e*hiit2a. Chest and lo $e r a c% 'ai n .Chills, fe!er, night s $eats , and he#o't"sisc.Fe!erof #ore than 1:F >:C? and naus ead. e ad ac he an d 'ho to 'ho i a16. 4ar%, a B-"ear-old client is rought to the e#ergenc"de'art#ent. e&stach"'neic and aferile and has a res'irator" rate of 6@ reaths#inute and hasa non'roducti!e cough. e recentl" had a cold. For#this histor" the client #a"ha!e $hich of the follo$ing conditions2a . A c u t e a s t h # a . =r on chi al 'ne u# on ia c.Chronic ostruc ti!e'ul#ona r" disease >C5P7 ?d . E # ' h " s e # a 1:. 4arichu $as gi!en #or'hine sulfate for 'ain. She is slee'ing and her res'irator" rate is :

reaths#inute. If action isn&t ta%en uic%l", she #ight ha!e$hich of the follo$ing reactions2a . A s t h # a a t t a c % . R e s ' i r a t o r "

a r r e s t c . S e i ) u r e d . ; a % e u ' o n h i s o $ n 10. A BB-"ear-old #ale client is ad#itted for electi!e %nee surger". Ph"sicale*a#ination


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re!eals shallo$ res'irations ut no sign of res'irator" distress.;hich of the follo$ing is a nor#al 'h"siologic change related to aging2a.Increas edelastic recoil of the lungs.Increased nu#er of functional ca'illaries in the al!eolic.7 ec re as ed re si dua l !o lu# ed .7e cr ea se d

!ital ca' acit"1@. Nurse Oohn is caring for a #ale client recei!ing lidocaine I.3. ;hich factor isthe #ost rele!ant to ad#inistration of this #edication2a.7ecrease in arterial o*"gen saturation >Sa5+? $hen #easured $ith a'ulse o*i#eter..Increase in s"ste#ic lood 'ressure c.Presence of 're#ature !entricular contractions >P3Cs? on a cardiac#onitor.d.Increase in intracranial 'ressure >ICP?.1B. Nurse Ronis caring for a #ale client ta%ing an anticoagulant. The nurseshould teach the client to(a .R e'ort incidents of diarrhea.. A!oid foods high

in !i ta #i n Hc .Use a s traight ra)or $hen sha!in g.d .T a% e as 'i ri n to 'a in re li ef . 1D. Nurse Jh"nnette is 're'aring a site for theinsertion of an I.3. catheter. Thenurse should treat e*cess hair at the site "(a. Je a! ing the hai r int ac t . S h a ! i n g t h e a r e a c.C li ''i ngthe hair in the aread.R e#o!ing the hai r $ith a de' ilator".1. Nurse 4ichelle is caring for an elderl" fe#ale $ith osteo'orosis.

;henteaching the client, the nurse should include infor#ation aout $hich #a


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side, re#o!e dangerous o6.:C? a cough'roducing "ello$ s'utu# and 'leuritic chest 'ain. The nursesus'ects this client#a" ha!e $hich of the follo$ing conditions2a.Adult res'irator" distress s"ndro#e >AR7S?.4"ocardial infarction>4 I? c . P n e u # o n i a d . T u e r c u l o s i s 6@. Nurse 5li!er is $or%ing in a out 'atient clinic. e has een alerted that thereis an outrea% oftuerculosis >T=?. ;hich of the follo$ing clients entering theclinic toda" #ost li%el" to ha!e T=2a.A 1@-"ear-old fe#ale high school

student.A 66-"ear-old da"-care $or%er c.A :6-"esr-old ho#eless #an $ith a histor" of alcoholis#d.A 0:- "ea r-o ld us iness#a n6B. 3irgie $ith a 'ositi!e 4antou* test result $ill e sent for a chest L-ra". Thenurse is a$are that $hich of the follo$ing reasons this isdone2a.To co nfir# the diagno sis

.To deter#i ne if a re'eat s%in test is neededc.To deter#ine the e*tent of lesionsd.To deter#ine if this is a 'ri#ar" orseconda r" infecti on6D. Henned" $ith acute asth#a sho$ing ins'irator" and e*'irator" $hee)es anda decreased forced e*'irator" !olu#e should etreated $ith $hich of thefollo$ing classes of #edication right a$a"2a. =e ta -a dr en er gi c l oc %e rs . = r o n c h o d i l a t o r s c . I n h a l e ds t e r o i d s d . 5 r a l s t e r o i d s 6. 4r. 3asue) 0@-"ear-old client $ith a :-"ear histor" of s#o%ing one to t$o'ac%s of cigarettes 'er da" has achronic cough 'roducing thic% s'utu#,'eri'heral ede#a and c"anotic nail eds. =ased on this infor#ation, he #ostli%el" has $hich of the follo$ingconditions2a.Adult res'irator" distress s"ndro#e >AR7S? . A s t h # a c.Chr onic o struc ti!e

ronc hitisd . E # ' h " s e # a Situation( Francis, age :@ is ad#itted to the hos'ital $ith diagnosis of ChronicJ"#'hoc"tic Jeu%e#ia.:. Thetreat#ent for 'atients $ith leu%e#ia is one #arro$ trans'lantation.;hich state#ent aout one #arro$ trans'lantation is not correct2a.The 'atientis under local anesthesia during the 'rocedure.The as'irated one #arro$ is #i*ed $ith he'ar in.c.T he a s'ira tion site is the'osterior or anterior il iac crest. d.The reci'ient recei!es c"clo'hos'ha#ide >C"to*an? for : consecuti!eda"s efore the 'rocedure.:1.

After se!eral da"s of ad#ission, Francis eco#es disoriented and co#'lainsof freuent headaches. The nurse in-charge first action $ould e(a . C a l lth e 'h "s ic ia n.7ocu#ent the 'atient&s status in his charts.c.Pre'are o*"gen treat#entd .R ai se th e si de ra il s:+.7uring routine care, Francis as%s the nurse, 8o$ can I e ane#ic if thisdisease causes increased #" $hite lood cell 'roduction29 The nurse in-chargeest res'onse $ould e that the increased nu#er of $hite lood cells >;=C? is( a.C ro$ d red lo od ce lls .Are not res'onsile for the ane#ia.c.Uses nutrients fro# other cellsd.a!e an anor#all"short life s'an of cells.:6. 7iagnostic assess#ent of Francis $ould 'roal" not re!eal(a.Predo#inance of

l"#holasts. J e u % o c " t o s i s c.Anor#al last cells in the one #arro$d.Ele !at ed thr o# oc" te cou nts ::. Roert, a 0B-


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"ear-old client $ith acute arterial occlusion of the left legundergoes an e#ergenc" e#olecto#". Si* hours later, the nurse isn&t ale tootain 'ulses in hisleft foot using 7o''ler ultrasound. The nurse i##ediatel"notifies the 'h"sician, and as%s her to 're'are the client for surger". As the nurseenters theclient&s roo# to 're'are hi#, he states that he $on&t ha!e an" #oresurger". ;hich of the follo$ing is the est initial res'onse " the nurse2a.E*'la inthe ris%s of not ha!ing the surger".Notif"ing the 'h"sician i##ediatel"c.Notif"ing the nursing su'er!isor d.Recordingthe client&s refusal in the nurses& notes:0. 7uring the endorse#ent, $hich of the follo$ing clients should the on-dut"nurse assess first2a.The0D-"ear-old client $ho $as ad#itted + da"s ago $ith heart failure,lood 'ressure of 1+@B@ ## g, and a res'irator" rate of ++

reaths#inute..The D-"ear-old client $ith end-stage right-sided heart failure, lood'ressure of BD0 ## g, and a 8do not resuscitate9

order c.The @+-"ear-old cl ient $ho $as ad# itted 1 da" ago $ith thro#o'hleitis and is recei!ing J.3. he'arind.The B0-"ear-old client $ho $as ad#itted 1 hour ago $ith ne$-onsetatrial firillation and is recei!ing J.3. dilitia)e# >Cardi)e#?:@. one", a +6-"ear old client co#'lainsof susternal chest 'ain and statesthat her heart feels li%e 8it&s racing out of the chest9. She re'orts no histor" of cardiac disorders. The nurse attaches herto a cardiac #onitor and notes sinustach"cardia $ith a rate of 16@eats#inutes. =reath sounds are clear and theres'irator" rate is +@ reaths#inutes.

;hich of the follo$ing drugs should thenurse uestion the client aout using2a . = a r i t u r a t e s

. 5 ' i o i d s c . C o c a i n e d . = e n ) o d i a ) e ' i n e s :B. A 01-"ear-old fe#ale client tells the nurse in-charge that she has found a'ainlesslu#' in her right reast during her #onthl" self-e*a#ination. ;hichassess#ent finding $ould strongl" suggest that this clientKs lu#' is cancerous2a.E!ersion of the righ t ni''le and #oile #ass.Non#oile #ass $ith irregular edgesc.4oile #ass that is soft and easil"delineatedd.Non'al'a le right a*il lar" l"#'h nodes:D. A 60-"ear-old client $ith !aginal cancer as%s the nurse, ;hat is the usualtreat#ent

for this t"'e of cancer2 ;hich treat#ent should the nurse na#e2a . S u r g e r " . C h e # o t h e r a ' " c . R a d i a t i o n d. I# #u no th er a' ":. Cristina undergoes a io's" of a sus'icious lesion. The io's" re'ortclassifies the lesion according to the TN4 staging s"ste# as follo$s( TIS, N,4. ;hat does this classification #ean2a.No e!idence of'ri#ar" tu#or, no anor#al regional l"#'h nodes, andno e!idence of distant #etastasis.Carcino#a in situ, no anor#al regional l"#'hnodes, and noe!idence of distant #etastasisc.CanKt assess tu#or or regional l"#'h nodes and no e!idence of #etastasisd.Carcino#ain situ, no de#onstrale #etastasis of the regional l"#'hnodes, and ascending degrees of distant #etastasis0. J"dia undergoes a lar"ngecto#"to treat lar"ngeal cancer. ;hen teachingthe client ho$ to care for the nec% sto#a, the nurse should include $hichinstruction2a.Hee' the sto#aun co !e re d. . He e' th e st o# a dr ". c.a!e a fa#il" #e#er 'erfor# sto#a care initiall" until "ou get usedto the'rocedure.d.Hee' the sto#a #oist. 01. A 6B-"ear-old client $ith uterine cancer as%s the nurse, ;hich is the #ostco##on t"'e of cancer in $o#en2 The nurse re'lies that itKs reastcancer.;hich t"'e of cancer causes the #ost deaths in $o#en2a . = r e a s t c a n c e r . J u n g c a n c e r c . = r a i n c a n c e r d.Colo nand rectal cancer 0+. Antonio $ith lung cancer de!elo's ornerKs s"ndro#e $hen the tu#or in!ades the ris and affects the s"#'athetic ner!eganglia. ;hen assessing for signs and s"#'to#s of this s"ndro#e, the nurse should note(a.#iosis , 'art ia l e"el id 'tos is , and anhidrosis onthe affected side of theface..chest 'ain, d"s'nea, cough, $eight loss, and fe!e r.c.ar# and shoulder 'ain and atro'h" ofar# and hand #us cles, oth on the affected side.d. hoar seness an d d"s'hagia. 06. 3ic as%s the nurse $hat PSA is. The nurse should re'l" that it stands for(a.'rostate-s'ecific antigen, $hich is used to screen for 'rostate cancer..'rotein seru# antigen, $hich is used todeter#ine 'rotein le!els.c.'neu#ococcal stre' antigen, $hich is a acteria that causes'neu#onia.d.Pa'anicolaou-s'ecificantigen, $hich is used to screen for cer!icalcancer.0:. ;hat is the #ost i#'ortant 'osto'erati!e instruction that nurse Hate #ustgi!e a client $hohas


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the diagnosis2a. St oo l e #a te st .Carcinoe#r"onic antigen >CEA?c. S i g # o i d o s c o ' " d.Ado#inal co#'utedto#ogra'h" >CT? scan 0@. 7uring a reast e*a#ination, $hich finding #ost strongl" suggests that theJu) has reast cancer2a. Slight as"##etr" of the reasts.. A fi*ednodular #ass $ith di#'ling of the o!erl"ing s%inc. =lood" discharge fro# the ni''led. 4ulti'le fir#, round, freel" #o!ale #asses that change $iththe#enstrual c"cle0B. A fe#ale client $ith cancer is eing e!aluated for 'ossile #etastasis. ;hichof the follo$ing is one of the #ost co##on #etastasissites for cancer cells2a . J i ! e r . C o l o n c. Re 'r od uc ti !e tr ac td.;hi te lood cells >;=Cs?0D. Nurse 4and" is 're'aring

a client for #agnetic resonance i#aging >4RI? toconfir# or rule out a s'inal cord lesion. 7uring the 4RI scan, $hich of thefollo$ing $ould 'ose a threatto the client2a.The cli ent lie s sti ll. .Th e cli ent as% s ue sti ons . c.The client hears thu#'ing sounds.d.The client $ears a $atch and $edding and.0. Nurse Cecile is teaching a fe#ale client aout 're!enting osteo'orosis.;hich of the follo$ing teaching 'oints iscorrect2a.5taining an L-ra" of the ones e!er" 6 "ears is reco##ended todetect one loss..To a!oid fractures, the client should a!oidstrenuous e*ercise.c.The reco##ended dail" allo$ance of calciu# #a" e found in a $ide!ariet" of foods.d.5taining the reco##endeddail" allo$ance of calciu# reuires ta%inga calciu# su''le#ent.@. =efore Oaco undergoes arthrosco'", the nurse re!ie$s the assess#entfindingsfor contraindications for this 'rocedure. ;hich finding is acontraindication2a. Ooint 'ain. Ooint defor#it"c. Ooint fle*ion of less than 0d. Oointstiffness @1. 4r. Rodrigue) is ad#itted $ith se!ere 'ain in the %nees. ;hich for# of arthritis is characteri)ed " urate de'osits and 73T? due to i##oilit" of the i'silateral sided."'oalu#ine#ia due to 'rotein esca'ing fro# an infla#edglo#erulus@:. eerden&snodes are a co##on sign of osteoarthritis. ;hich of the follo$ingstate#ent is correct aout this defor#it"2a.It a''ears onl" in #en.Ita''ears on the distal inter'halangeal


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doctor orders ed rest, a $et-to-dr" dressing change e!er" shift, and lood glucose #onitoring efore #ealsand edti#e. ;h" are $et-to-dr" dressingsused for this client2a.The" contain e*udate and 'ro!ide a #oist $ound en!iron#ent..The" 'rotect the $ound fro# #echanical trau#aand 'ro#ote healing.c.The" deride the $ound and 'ro#ote healing " secondar" intention.d.The" 're!ent the entrance of#icroorganis#s and #ini#i)e $ounddisco#fort.B1. Nurse en" is caring for a client in acute addisonian crisis. ;hich laorator"data $ould thenurse e*'ect to find2a . " ' e r % a l e # i a

.Reduced lood urea nitrogen >=UN? c . " ' e r n a t r e # i a d . " ' e r g l " c e # i a B+. A client is ad#itted for treat#ent of the s"ndro#e

of ina''ro'riate antidiuretichor#one >SIA7?. ;hich nursing inter!ention is a''ro'riate2a.Infusing I.3. fluids ra'idl" asordered.Encouraging increased oral inta%ec . R e s t r i c t i n g f l u i d s d.Ad#inistering glucose-containing I.3. fluids as orderedB6. A fe#ale client tells nurse Ni%%i that she has een $or%ing hard for the last 6#onths to control her t"'e + diaetes #ellitus $ith diet and e*ercise.Todeter#ine the effecti!eness of the clientKs efforts, the nurse should chec%(a. urine gluc ose le!el. .fas ting lood gl uc osele !el. c.s er u# fru cto sa #i ne le !el. d.gl "cos"lated he#ogloin le!el. B:. Nurse Trinit" ad#inistered neutral 'rota#ine agedorn>NP? insulin to adiaetic client at B a.#. At $hat ti#e $ould the nurse e*'ect the client to e #ostat ris% for a h"'ogl"ce#ic reaction2a . 1 ( a # . N o o n c . : ( ' # d . 1 ( ' # B0. The adrenal corte* is res'onsile for 'roducing $hich sustances2a.Glucocorticoids and androgens.Catechola#ines and e'ine'hrinec.4ineralocorticoids andcatechola#in esd.Nore'ine'hrine and e'ine'hrineB@. 5n the third da" after a 'artial th"roidecto#", Proserfina e*hiits #usclet$itchingand h"'erirritailit" of the ner!ous s"ste#. ;hen uestioned, the clientre'orts nu#ness and tingling of the #outh and fingerti's. Sus'ecting a life-

threatening electrol"te disturance, the nurse notifies the surgeon i##ediatel".;hich electrol"te disturance #ost co##onl" follo$s th"roid surger"2a . " ' o c a l c e # i a . " ' o n a t r e # i a c . " ' e r % a l e # i a d . " ' e r # a g n e s e # i a BB. ;hich laorator" test !alue is ele!ated in clients $ho s#o%e and canKt eused as a general indicator of cancer2a.Acid'hos'hatase le!el.Seru# calcitonin le!elc. Al%aline 'hos'hatase le!eld.Carcinoe#r"onic antigen le!elBD. Francis

$ith ane#ia has een ad#itted to the #edical-surgical unit. ;hichassess#ent findings are characteristic of iron-deficienc" ane#ia2a.Nights s$eats, $eight loss, and diarrhea.7"s'nea, tach"cardia, and 'allo r c.N ausea, !o#iting, and ano re*iad .Itching, rash, and


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'rolonged as'irin thera'". These include(a. $ e i g h t g a i n . . f i ne #o t or tr e #o r s. c.r es' ira tor " ac ido sis .d. il ate ral hea rin gloss.D:. A +6-"ear-old client is diagnosed $ith hu#an i##unodeficienc" !irus >I3?.After reco!ering fro# the initial shoc% of the diagnosis, the cliente*'resses adesire to learn as #uch as 'ossile aout I3 and acuired i##unodeficienc"s"ndro#e >AI7S?. ;hen teaching the client aout thei##une s"ste#, the nursestates that ada'ti!e i##unit" is 'ro!ided " $hich t"'e of $hite lood cell2a . N e u t r o ' h i l . = a s o ' h i l c . 4 o n o c " t e d . J " # ' h o c " t e D0. In an indi!idual $ith SI3?, the nurse e*'ects the 'h"sician to order(a.E-rosettei##unofluorescence..uantification of T-l"#'hoc"tes.c.en)"#e-lin%ed i##unosorent assa" >EJISA?.d.;estern lottest $ith EJISA.DD. A co#'lete lood count is co##onl" 'erfor#ed efore a Ooe goes intosurger". ;hat does this test see% to identif"2a.Potential he'atic d"sfunction indicated " decreased lood ureanitrogen >=UN? and creatinine le!els.Jo$ le!els of urine constituentsnor#all" e*creted in the urinec.Anor#all" lo$ he#atocrit >CT? and he#ogloin >? le!elsd.Electrol"te i#alance that could affectthe loodKs ailit" to coagulate'ro'erl"D. ;hile #onitoring a client for the de!elo'#ent of disse#inated intra!ascular coagulation >7IC?, the nurseshould ta%e note of $hat assess#ent 'ara#eters2a.Platelet count, 'rothro#in ti#e, and 'artial thro#o'lastin ti#e.Platelet count, loodglucose le!els, and $hite lood cell >;=C? countc.Thro#in ti#e, calciu# le !els, and 'otass iu# le!els d.Fir inogen le!el, ;=C,and 'la telet count . ;hen ta%ing a dietar" histor" fro# a ne$l" ad#itted fe#ale client, Nurse Jenshould re#e#er that $hich of the follo$ingfoods is a co##on allergen2a . = r e a d . C a r r o t s c . 5 r a n g e d . S t r a $ e r r i e s 1. Nurse Oohn is caring for clients in theout'atient clinic. ;hich of the follo$ing'hone calls should the nurse return first2a.A client $ith he'atitis A $ho states, 84" ar#s and legs areitching.9.A client $ith cast on the right leg $ho states, 8I ha!e a funn" feeling in#" right leg.9c.A client $ith osteo#"elitis of the s'ine

$ho states, 8I a# so nauseousthat I can&t eat.9 d.A client $ith rheu#atoid arthritis $ho states, 8I a# ha!ing trouleslee'ing.9+. Nurse Sarah is caring for clients on the surgical floor and has


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'illo$s to 'osition the client.0. Nurse Tina 're'ares a client for 'eritoneal dial"sis. ;hich of the follo$ingactions should the nurse ta%e first2a.Assess for a ruit and a thrill..;ar# the dial"sate solution.c.Position the client on the left side.d.Insert a Fole"catheter @. Nurse Oannah teaches an elderl" client $ith right-sided $ea%ness ho$ to usecane. ;hich of the follo$ing eha!iors, if de#onstrated " the client tothe nurse,indicates that the teaching $as effecti!e2a.The client holds the cane $ith his right hand, #o!es the can for$ardfollo$ed " the rightleg, and then #o!es the left leg..The client holds the cane $ith his right hand, #o!es the cane for$ardfollo$ed " his left leg, and then #o!es

the right leg.c.The client holds the cane $ith his left hand, #o!es the cane for$ardfollo$ed " the right leg, and then #o!es the left leg.d.Theclient holds the cane $ith his left hand, #o!es the cane for$ardfollo$ed " his left leg, and then #o!es the right leg.B. An elderl" client isad#itted to the nursing ho#e setting. The client isoccasionall" confused and her gait is often unstead". ;hich of the follo$ingactions, if ta%en " thenurse, is #ost a''ro'riate2a.As% the $o#an&s fa#il" to 'ro!ide 'ersonal ite#s such as 'hotos or #e#entos..Select a roo# $ith a ed "the door so the $o#an can loo% do$n thehall.c.Suggest the $o#an eat her #eals in the roo# $ith her roo##ate.d.Encourage the

$o#an to a#ulate in the halls t$ice a da".D. Nurse E!angeline teaches an elderl" client ho$ to use a standard alu#inu#$al%er. ;hich of thefollo$ing eha!iors, if de#onstrated " the client, indicatesthat the nurse&s teaching $as effecti!e2a.The client slo$l" 'ushes the $al%er for$ard 1+inches, then ta%ess#all ste's for$ard $hile leaning on the $al%er..The client lifts the $al%er, #o!es it for$ard 1 inches, and thenta%esse!eral s#all ste's for$ard.c.The client su''orts his $eight on the $al%er $hile ad!ancing it for$ard,then ta%es s#all ste's $hile

alancing on the $al%er.d.The client slides the $al%er 1D inches for$ard, then ta%es s#all ste's$hile holding onto the $al%er for alance.. Nurse 7eric is su'er!ising a grou' ofelderl" clients in a residential ho#esetting. The nurse %no$s that the elderl" are at greater ris% of de!elo'ingsensor" de'ri!ation for $hat reason2a.Increased sensiti!it" to the side effects of #edications..7ecreased !isual, auditor", and gustator" ailit ies.c .Isola tion fro#their fa#ilies and fa#iliar surro undings.d.7ecrease #usculos%eletal function and #oilit". 1. A #ale client $ith e#'h"se#a eco#es restless and confused. ;hat ste'should nurse Oas#ine ta%e ne*t2a.Encou ra ge the clien t to'erfor# 'ursed li' reathing..Chec% the client&s te#'erature.c.Assess the client&s 'otassiu# le!el.d.Increase the client&so*"gen flo$ rate.

TEST I3 - Care of Clients $ith Ph"siologic and Ps"chosocial Alterations1.Rand" has undergone %idne" trans'lant, $hat assess#ent $ould 'ro#'tNurse Hatrina to sus'ect organ re


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c.T"'e + diaetesd . " ' e r t h " r o i d i s # 0.Trac" is recei!ing co#ination che#othera'" for treat#ent of #etastaticcarcino#a. Nurse Ru"should #onitor the client for the s"ste#ic sideeffect of(a . A s c i t e s . N " s t a g # u s c . J e u % o ' e n i a d . P o l " c " t h e # i a @.Nor#a, $ith recent colosto#" e*'resses concern aout the inailit" tocontrol the 'assage of gas. Nurse 5li!er should suggest that theclient'lan to(a.Eli#inate foods high in cellulose..7ecrease fluid inta%e at #eal ti#es.c.A!oid foods that in the 'ast causedflatus.d.Adhere to a land diet 'rior to social e!ents.B.Nurse Ron egins to teach a #ale client ho$ to 'erfor#

colosto#"irrigations. The nurse $ould e!aluate that the instructions $ereunderstood $hen the client states, 8I should(a.Jie on #" left side $hileinstilling the irrigating solution.9.Hee' the irrigating container less than 1D inches ao!e the sto#a.9c.Instill a #ini#u# of 1+ #l ofirrigating solution to sti#ulatee!acuation of the o$el.9d.Insert the irrigating catheter dee'er into the sto#a if cra#'ingoccurs during the'rocedure.9D.Patric% is in the oliguric 'hase of acute tuular necrosis and ise*'eriencing fluid and electrol"te i#alances. The client isso#e$hatconfused and co#'lains of nausea and #uscle $ea%ness. As 'art of the'rescried thera'" to correct this electrol"te i#alance, the nurse

$oulde*'ect to(a .Ad#iniste r Ha"e*alate.Restric t foods high in 'rotein c.Inc rease oral inta%e of cheese and#il%.d.Ad#inister large a#ounts of nor#al saline !ia I.3..4ario has urn in


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cancertherefore, she should ha!e a Pa'anicolaou >Pa'? s#ear annuall"..The #ost co##on treat#ent is #etronida)ole >Flag"l?, $hichshoulderadicate the 'role# $ithin B to 1 da"s.c.The 'otential for trans#ission to her se*ual 'artner $ill eeli#inated if condo#s are usede!er" ti#e the" ha!e se*ualintercourse.d.The hu#an 'a'illo#a!irus >P3?, $hich causes cond"lo#ataacu#inata, canKt e trans#itted duringoral se*.1D.4aritess $as recentl" diagnosed $ith a genitourinar" 'role# and iseing e*a#ined in the e#ergenc" de'art#ent. ;hen 'al'ating theher %idne"s, the nurse should %ee' $hich anato#ical fact in #ind2a.The left %idne" usuall" is slightl" higher than the right one..The %idne"sare situated +? long and + to 6 c#> to 1-1D?

$ide.d.The %idne"s lie et$een the 1th and 1+th thoracic !erterae.1.Oestoni $ith chronic renal failure >CRF? is ad#itted to the urolog" unit.

Thenurse is a$are that the diagnostic test are consistent $ith CRF if the resultis(a.Increased ' $ith decreased h"drogen ions..Increasedseru# le!els of 'otassiu#, #agnesiu#, and calciu#.c.=lood urea nitrogen >=UN? 1 #gdl and seru# creatinine @.0 #gdl. d.Uric acid anal"sis 6.0 #gdl and 'henolsulfon'hthalein >PSP?e*cretion B0.+.Hatrina has an anor#al result on a Pa'anicolaou test. After ad#ittingthat she read her chart $hile the nurse $as out of the roo#, Hatrina as%s$hatd"s'lasia#eans. ;hich definition should the nurse 'ro!ide2a.Presence of co#'letel" undifferentiated tu#or cells that donKtrese#le cells of the tissues of their origin..Increase in the nu#er of nor#al cells in a nor#al arrange#ent ina tissue or an organ.c.Re'lace#ent of one t"'e of full"differentiated cell " another intissues $here the second t"'e nor#all" isnKt found.d.Alteration in the si)e, sha'e, and organi)ation ofdifferentiated cells.+1.7uring a routine chec%u', Nurse 4ariane assesses a #ale client $ithacuired i##unodeficienc" s"ndro#e>AI7S?for signs and s"#'to#s of cancer.

;hat is the #ost co##on AI7S-related cancer2a.Sua#ous cell car cino#a . 4 u l t i ' l e # " e l o # a c . J e u % e # i a d . H a ' o s i K ss a r c o # a ++.Ricardo is scheduled for a 'rostatecto#", and the anesthesiologist 'lansto use a s'inal >suarachnoid? loc% during surger". In theo'eratingroo#, the nurse 'ositions the client according to the anesthesiologistKsinstructions. ;h" does the client reuire s'ecial 'ositioning for this t"'eof anesthesia2a.To ' re! ent con fus ion . To ' r e! e nt se i )u r e s c.To 're!ent cereros'inal fluid >CSF? lea%aged.To 're!entcardiac arrh"th#ias +6.A #ale client had a ne'hrecto#" + da"s ago and is no$ co#'laining of ado#inal 'ressure and nausea. The first nursingaction should e to(a.Ausculta te o$el sounds ..Pal 'ate the ado#e n.c.Ch ange the clie ntKs 'osit ion.d. Inser t a rect altue.+:.;ilfredo $ith a recent histor" of rectal leeding is eing 're'ared for acolonosco'". o$ should the nurse Patricia 'osition the client for thistestinitiall"2

a.J"ing on the right side $ith legs straight.J"ing on the left side $ith %nees entc. Pro ne $it h t he tor so ele !at ed d.=ento! er $ith ha nds touchin g the fl oo r +0.A #ale client $ith infla##ator" o$el disease undergoes an ileosto#".5n the first da" after surger",Nurse 5li!er notes that the clientKs sto#aa''ears dus%". o$ should the nurse inter'ret this finding2a.=lood su''l" to the sto#a has eeninterru'ted..This is a nor#al finding 1 da" af ter surger".c.The osto#" ag should e ad


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+? !alue of D ## g..Uri ne out 'ut of + #l hou r.c .;h ite 'ul #on ar" sec ret ion s. d.Rectal te#'erature of 1.@ F >6DC?.+D.4r. 4endo)a $ho has suffered a cerero!ascular accident>C3A?is too$ea% to #o!e on his o$n. To hel' the client a!oid 'ressure ulcers, NurseCeliashould(a.Turn hi# freuentl"..Perfor# 'assi!e range-of-#otion >R54? e*ercises.c.Reduce the clientKs fluidint a%e .d.Encourage the client to use a footoard.

+.Nurse 4aria 'lans to ad#inister de*a#ethasone crea# to a fe#ale client$ho has der#atitis o!er the anterior chest. o$ should the nurse a''l"thisto'ical agent2a.;ith a circular #otion, to enhance asor't ion..;ith an u'$ard #otion, to increase lood su''l" to theaffectedareac.In long, e!en, out$ard, and do$n$ard stro%es in the direction of hair gro$thd.In long, e!en, out$ard, and u'$ard stro%esin the direction o''ositehair gro$th6.Nurse Hate is a$are that one of the follo$ing classes of #edication'rotect the ische#ic #"ocardiu# "

loc%ing catechola#ines ands"#'athetic ner!e sti#ulation is(a .=eta -adrenergic lo c%e rs. Calciu# chann el loc%e r c . N a r c o t i c s d . N i t r a t e s 61.A #ale client has J7J? le!el. ;hich of the follo$ingdietar" #odifications is not a''ro'riate for this client2a.Fier inta%e of +0 to 6 gdail"

.Jes s than 6 of calories for# fatc.Cholesterol inta%e of less than 6 #g dai l"d .Jess than 1 of calories fro#satur ate d fat 6:. A 6B-"ear-old #ale client $as ad#itted to the coronar" care unit >CCU? +da"s ago $ith an acute #"ocardial infarction. ;hich of thefollo$ing actions$ould reach the client confidentialit"2a.The CCU nurse gi!es a !eral re'ort to the nurse on the tele#etr"unit eforetransferring the client to that unit.The CCU nurse notifies the on-call 'h"sician aout a change in theclient&s conditionc.The e#ergenc"de'art#ent nurse calls u' the latestelectrocardiogra# results to chec% the client&s 'rogress.d.At the client&s reuest, the CCU nurseu'dates the client&s $ife onhis condition60. A #ale client arri!ing in the e#ergenc" de'art#ent is recei!ingcardio'ul#onar" resuscitation fro#'ara#edics $ho are gi!ing !entilationsthrough an endotracheal >ET? tue that the" 'laced in the client&s ho#e. 7uring a'ause in co#'ressions, the

cardiac #onitor sho$s narro$ RS co#'le*es anda heart rate of eats#inute $ith a 'al'ale 'ulse. ;hich of the follo$ing actionsshould the nurseta%e first2a.Start an J.3. line and ad#inister a#iodarone >Cardarone?, 6 #gJ.3. o!er 1 #inutes..Chec% endotracheal tu e'lace# ent. c.5tain an arteri al lood gas >A=G? sa#' le.d .Ad#ini ster atro'ine, 1 # g J.3. 6@. After cardiac surger", a client&s lood'ressure #easures 1+@D ## g.Nurse Hatrina deter#ines that #ean arterial 'ressure >4AP? is $hich of thefollo$ing2a . : @ # # g . D # # g c . 0 # # g d . # # g 6B. A fe#ale client arri!es at the e#ergenc" de'art#ent $ith chest andsto#ach'ain and a re'ort of lac% tarr" stool for se!eral #onths. ;hich of the follo$ingorder should the nurse 5li!er antici'ate2a.Cardiac #onitor,o*"gen, creatine %inase and lactate deh"drogenase le!els.Prothro#in ti#e, 'artial thro#o'lastin ti#e, firinogen and firins'lit'roduct !alues.

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c.Electrocardiogra#, co#'lete lood count, testing for occult lood,co#'rehensi!e seru# #etaolic 'anel.d.Electroence'halogra#,al%aline 'hos'hatase and as'artate a#inotransferasele!els, asic seru# #etaolic 'anel6D. 4acario had coronar" arter" "'ass graft >CA=G?surger" 6 da"s ago. ;hichof the follo$ing conditions is sus'ected " the nurse $hen a decrease in 'lateletcount fro# +6, ul to 0, ul is noted2a . P a n c " t o ' e n i a .Idio'athic thro#oc"to'e#ic 'ur'ura >ITP?c.7isse#inated intra!ascular coagulation>7IC?d.e'arin-associated thro#osis and thro#oc"to'enia >ATT?6. ;hich of the follo$ing drugs $ould e ordered " the 'h"sician toi#'ro!ethe 'latelet count in a #ale client $ith idio'athic thro#oc"to'enic 'ur'ura>ITP?2a .Acet"lsalic"lic acid>A SA ? . C o r t i c o s t e r o i d s c . 4 e t h o t r e ) a t e d . 3 i t a # i n H :. A fe#ale client is scheduled to recei!e a heart !al!e re'lace#ent $ith

a'orcine !al!e. ;hich of the follo$ing t"'es of trans'lant is this2a . A l l o g e n e i c . A u t o l o g o u s c . S " n g e n e i c d . L e n o g e n e i c :1. 4arco falls off his ic"cle and inI3? infection to the de!elo'#ent of acuiredi##unodeficienc" s"ndro#e>AI7S?2a. Je ss th an 0 "e ar s . 0 t o B " e a r s c . 1 " e a r s d. 4o re th an 1 "e ar s :B. An 1D-"ear-old #ale client ad#itted

$ith heat stro%e egins to sho$ signs of disse#inated intra!ascular coagulation >7IC?. ;hich of the follo$ing laorator"findings is #ost consistent $ith7IC2a.Jo$ 'latelet count.Ele!ated firinogen le!elsc.Jo$ le!els of firin degradation 'roductsd.Reduced'rothro#in ti#e :D. 4ario co#es to the clinic co#'laining of fe!er, drenching night s$eats, andune*'lained $eight loss o!er the 'ast 6 #onths. Ph"sical e*a#inationre!eals asingle enlarged su'racla!icular l"#'h node. ;hich of the follo$ing is the #ost'roale diagnosis2a . I n f l u e n ) a . S i c % l e c e l la n e # i a c . J e u % e # i a d . o d g % i n & s d i s e a s e :. A #ale client $ith a gunshot $ound reuires an e#ergenc" loodtransfusion. is lood

t"'e is A= negati!e. ;hich lood t"'e $ould e the safestfor hi# to recei!e2a. A = R h - ' o s i t i ! e . A R h - ' o s i t i ! e c . A R h -n e g a t i ! e d . 5 R h - ' o s i t i ! eSituation( Stac" is diagnosed $ith acute l"#'hoid leu%e#ia >AJJ? and eginning che#othera'".0. Stac" is discharged fro# the hos'ital follo$ing her che#othera'" treat#ents.;hich state#ent of Stac"&s #other indicated that she understands

$hen she $illcontact the 'h"sician2a.8I should contact the 'h"sician if Stac" has difficult" in slee'ing9..8I $ill call #" doctor if Stac" has'ersistent !o#iting and diarrhea9.c.84" 'h"sician should e called if Stac" is irritale and unha''"9.d.8Should Stac" ha!e continuedhair loss, I need to call the doctor9.01. Stac"&s #other states to the nurse that it is hard to see Stac" $ith no hair.The est res'onse for the nurseis(a.8S tac" loo%s !er" nice $earing a hat9. .8ou should not $orr" aout her hair,


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.A ''l" !iscous Jid ocaine to oral ulc ers as needed.c.Use le#on gl"cerine s$as e!er" + hours.d .Rinse #outh $ith"drogen Pe ro*ide.06. 7uring the ad#inistration of che#othera'" agents, Nurse 5li!er oser!edthat the I3 site is red and s$ollen, $hen the I3 istouched Stac" shouts in 'ain.The first nursing action to ta%e is(a.Notif" th e 'h"sician .F lus h the I3 line $ith sal inesolutionc.I##ediate l" disc onti nue the infusion d.A''l" an ice 'ac% to the site, follo$ed " $ar# co#'ress.0:. The ter# 8lue

loater9 refers to a #ale client $hich of the follo$ingconditions2a.Adult res'irator" distress s"ndro#e >AR7S? . A s t h # a c.Chronicos truc ti!e ronchitis d . E # ' h " s e # a 00. The ter# 8'in% 'uffer9 refers to the fe#ale client $ith $hich of the follo$ingconditions2

a.Adult res'irator" distress s"ndro#e >AR7S? . A s t h # a c.Chronic ostruct i!e ronchit isd . E # ' h " s e # a 0@. Ooseis in danger of res'irator" arrest follo$ing the ad#inistration of anarcotic analgesic. An arterial lood gas !alue is otained. Nurse 5li!er $oulde*'ect the'aco+ to e $hich of the follo$ing !alues2a . 1 0 # # g . 6 # # g c . : # # g d . D # # g 0B. Ti#oth"&sarterial lood gas >A=G? results are as follo$s ' B.1@ Paco+ D## g Pao+ :@ ## g C56- +:#EJ Sao+ D1. This A=G resultre'resents

$hich of the follo$ing conditions2a . 4 e t a o l i c a c i d o s i s .4e taolic al%alosis c . R e s ' i r a t o r " a c i d o s i s d.Res'irator " al%alosis 0D. Nor#a has started a ne$ drug for h"'ertension. Thirt" #inutes after sheta%es the drug, she de!elo's chest tightnessand eco#es short of reath andtach"'neic. She has a decreased le!el of consciousness. These signs indicate$hich of the follo$ing conditions2a . A s t h # a a t t a c % . P u l # o n a r " e # o l i s # c . R e s ' i r a t o r " f a i l u r e d . R h e u # a t o i d a r t h r i t i sSituation( 4r. Gon)ales $as ad#itted to the hos'ital $ith ascites and R=C? count, increased $hite lood >;=C? count..Se!ere lo$er ac% 'ain, decreased lood 'ressure,decreasedR=C count, increased ;=C count.c.Se!ere lo$er ac% 'ain, decreased lood 'ressure, decreasedR=C count, decreased R=C count,decreased ;=C count.d.Inter#itted lo$er ac% 'ain, decreased lood 'ressure, decreasedR=C count, increased ;=C count.@:. Afterundergoing a cardiac catheteri)ation, Trac" has a large 'uddle of loodunder his uttoc%s. ;hich of the follo$ing ste's should the nurse ta%e first2a . C a l l f o r h e l ' . . 5 ta in !i ta l si gn sc .As% the client to 8lift u'9 d.A''l" glo!es and assess the groin site@0. ;hich ofthe follo$ing treat#ent is a suitale surgical inter!ention for a client$ith unstale angina2a.Cardiaccat het eri )at ion . E ch o c ar di o gr a# c . N i t r o g l " c e r i n d.Percutaneous translu#inal coronar" angio'last" >PTCA?@@. The nurseis a$are that the follo$ing ter#s used to descrie reduced cardiacout'ut and 'erfusion i#'air#ent due to ineffecti!e 'u#'ing of the heartis(a .A na' h"l act ic sho c% .C ard io ge nic sho c%c .7i str iu ti! e sho c% d.4"ocardial infarct ion >4I?@B. A client $ithh"'ertension as% the nurse $hich factors can cause lood'ressure to dro' to nor#al le!els2a.Hidne"s& e*cret ion to sodiu# onl"..Hidne"s &

retention of sodiu# and $ater c.Hidne"s& e*cretion of sodiu# and $ater

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d.Hidne"s& retention of sodiu# and e*cretion of $ater @D. Nurse Rose is a$are that the state#ent that est e*'lains

$h" furose#ide >Jasi*?is ad#inistered to treat h"'ertension is(a.It dilates 'eri'hera l loo d !essels.. It decrea ses s"#' athe ticcardio accel eratio n.c.It inhii ts the angiotensin- co!erting en)"#es d.It inhiits reasor'tion of sodiu# and $ater in the loo' ofenle.@. Nurse Ni%%i %no$s that laorator" results su''orts the diagnosis of s"ste#iclu'us er"the#atosus >SJE? is(a.El a!ated seru#co#'le#ent le!el.Thro#oc"tosis, ele!ated sedi#entation ratec.Panc"to'enia, ele!ated antinuclear antiod" >ANA?titer d.Jeu%oc"sis, ele!ated lood urea nitrogen >=UN? and creatinine le!elsB. Arnold, a 1-"ear-old client $ith a #ild concussion is

discharged fro# thee#ergenc" de'art#ent. =efore discharge, he co#'lains of a headache. ;henoffered aceta#ino'hen, his #other tells the nurse theheadache is se!ere andshe $ould li%e her son to ha!e so#ething stronger. ;hich of the follo$ingres'onses " the nurse is a''ro'riate2a.8our sonhad a #ild concussion, aceta#ino'hen is strong enough.9.8As'irin is a!oided ecause of the danger of Re"e&s s"ndro#e inchildren or

"oung adults.9c.8Narcotics are a!oided after a head inICP?.E#ergent the client is 'oorl" o*"genatedc . N o r # a l d.Significant the client hasal !eolar h"'o! en ti la tion B+. ;hen 'rioriti)ing care, $hich of the follo$ing clients should the nurse 5li!iaassess first2 a.A 1B-"ear-old clients +:-hours 'osta''endecto#".A 66-"ear-old client $ith a recent diagnosis of Guillain-=arre s"ndro#ec.A0-"ear-old client 6 da"s 'ost#"ocardial infarctiond.A 0-"ear-old client $ith di!erticulitisB6. OP has een diagnosed $ith goutand $ants to %no$ $h" colchicine is usedin the treat#ent of gout. ;hich of the follo$ing actions of colchicines e*'lains$h" it&s effecti!e for gout2a. Re 'l ac es es tr og en .7ecr eases infe ctio nc.7ec rease s infla ##atio nd.7ecreases one de#inerali)ationB:. Nor#a as%sfor infor#ation aout osteoarthritis. ;hich of the follo$ingstate#ents aout osteoarthritis is correct2a.5steo arthrit is is rarel "deilitating.5steoarthritis is a rare for# of arthritisc.5steoarthritis is the #ost co##on for# of arthritisd.5steoarthritisafflicts 'eo'le o!er @B0. Ru" is recei!ing th"roid re'lace#ent thera'" de!elo's the flu and forgets tota%e her th"roid re'lace#ent #edicine. Thenurse understands that s%i''ing this#edication $ill 'ut the client at ris% for de!elo'ing $hich of the follo$ing life-threatening co#'lications2a . E * o ' h t h a l # o s . T h " r o i d s t o r # c . 4 " * e d e # a c o # a d. Ti i al #" *e de #a B@. Nurse Sugar is assessing a client $ithCushingKs s"ndro#e. ;hichoser!ation should the nurse re'ort to the 'h"sician i##ediatel"2a.Pitting ede#a of the legs.An irregulara' ic al 'u ls ec . 7 r " # u c o u s # e # r a n e s d . F r e u e n t u r i n a t i o n BB. C"rill $ith se!ere head trau#a sustained in a car accident isad#itted to theintensi!e care unit. Thirt"-si* hours later, the clientKs urine out'ut suddenl" risesao!e + #lhour, leading the nurse to sus'ect diaetes

insi'idus. ;hichlaorator" findings su''ort the nurseKs sus'icion of diaetes insi'idus2 a.Ao!e-nor#al urine and seru# os#olalit" le!els.=elo$-nor#al urine and seru# os#olalit" le!elsc.Ao!e-nor#al urineos#olalit" le!el, elo$-nor#al seru# os#olalit"le!eld.=elo$-nor#al urine os#olalit" le!el, ao!e-nor#al seru# os#olalit"le!elBD.Oo#ari is diagnosed $ith h"'eros#olar h"'ergl"ce#ic non%etotic s"ndro#e>NS? is staili)ed and 're'ared for discharge. ;hen 're'aring the clientfor discharge and ho#e #anage#ent, $hich of the follo$ing state#ents indicatesthat the client understands her condition and ho$ to control it2a.Ican a!oid getting sic% " not eco#ing deh"drated and " 'a"ingattention to #" need to urinate, drin%, or eat #ore than usual..If Ie*'erience tre#ling, $ea%ness, and headache, I should drin% aglass of soda that contains sugar.c.I $ill ha!e to #onitor #" lood glucosele!el closel" and notif" the'h"sician if itKs constantl" ele!ated.d.If I egin to feel es'eciall" hungr" and thirst", IKll eat a snac% highincaroh"drates.B. A @@-"ear-old client has een co#'laining of slee'ing #ore, increasedurination, anore*ia, $ea%ness, irr

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