2 days after an abdominal hysterectomy, an elderly purchaser with diabetes Mellitus Type II has
a syncopal episode. Her vital symptoms are inside ordinary limites and her sugar is 325 mg/dL.
What intervention ought to the nurse put in force first?
A. Give the client four oz of orange juice
B. Administer next scheduled dose of metformin (Glucophage)
C. Cancel the customers dinner tray
D. Administer normal insulin in keeping with sliding scale - ANS-D. Administer everyday insulin
per sliding scale
36 hours after transport, the nurse determines a consumer's fundus is just above the umbilicus
and displaced to the proper of midline. What movement need to the nurse take first?
A. Palpate the bladder for distention
B. Ask the consumer when her remaining bowel movement befell
C. Catheterize the consumer and document the quantity
D. Assess the amount of lochia - ANS-A. Palpate the bladder for distention
four hours after administration of 20U of normal insulin, the consumer becomes shake and
diaphoretic. What motion should the nurse take?
A. Encourage the customer to excercise
B. Administer a PRN dose of 10U of normal insulin
C. Give the patron crackers and milk
D. Record the consumer's reaction at the diabetic waft sheet - ANS-C. Give the consumer
crackers and milk
A 26 12 months-vintage primigravida who delivered a 7-pound male infant 26 hours in the past
tells the nurse that she is harassed approximately while she and her husband can go back to
having sexual intercourse. What data ought to the nurse fortify with this purchaser?
A. They can have sex whilst the episiotomy is healed and the lochial glide has stopped
B. They ought to wait to resume sexual sports till the fatigue diverse with a brand new toddler
has passed
C. They can resume sexual interest at 6 weeks postpartum
D. It is first-rate to attend till each events sense as much as having sexual sex - ANS-A. They
may have intercourse while the episiotomy is healed and the lochial drift has stopped
A 26-yr-old gravida 4, para zero had a spontaneous abortion at nine weeks gestation. At
one-residence publish dilation and curettage (D&C) the nurse examine the crucial symptoms
and vaginal bleeding. The patron starts offevolved to cry softly. How should the nurse interfere?
A. Offer to name the social worker to talk about the possiblity of abortion
,B. Reassure the patron that the infertility specialist can assist
C. Express sorrow for the client's grief and provide to sit down together with her
D. Chart the crucial symptoms and quantity of vaginal bleeding - ANS-C. Express sorrow for the
consumer's grief and provide to sit down together with her
A three 12 months-antique admitted with fever of unknown beginning (FUO) has began vomiting
within the past 1/2 hour. The infant's temperature is one hundred and one.Eighty F, and the
closing dose of antipyretic remedy was given five hours in the past. The child has prescriptions
of acetaminophen (Tylenol) a hundred and sixty MG per five mL elixir or 160 mg suppositories
PRN fever or pain. What motion must the nurse take right now?
A. Make the child NPO and keep all medications untill the vomiting has stopped
B. Give acetaminophen elixir to make sure the kid's cooperation with swallowing
C. Notify the healthcare company that the child's fever has come to be dangerously high
D. Use an acetaminophen suppository for the fever for the reason that the child is vomiting -
ANS-A. Make the kid NPO and hold all medications untill the vomiting has stopped
A three-week-old little one is admitted for surgical repair of Pyloric Stenosis. What interventions
need to the nurse anticipate to put in force to establish hydration within the on the spot
postoperative duration?
A. Diaper weights and urin particular gravity
B. Gastronomy feedings in supine role
C. Nipple feedings with glucose water
D. Gavage feedings with 15mL of system - ANS-C. Nipple feedings with glucose water
A 6-month antique male with Bronchiolitis is admitted to the health facility. In tracking the
breathing status of this toddler, which symptom shows the nurse that he is experiencing
Respiratory Distress?
A. Respiratory of 62 breaths/minute
B. Abdominal respiration
C. A excessive-pitched cry
D. Dry flushed skin - ANS-C. A excessive-pitched cry
A 60 12 months-antique customer with cancer of the liver is in Hepatic Coma and unresponsive.
What have to the nurse say to family contributors who're inquiring about the situation in their
loved one?
A. "Your cherished one's circumstance is very vital, and there was no response within the
remaining 24 hours"
B. "The nurses have no longer been able to arouse the purchaser and the healthcare company
is aware of the outcome."
C. "You need to discuss the circumstance with the charge nurse in a family convention."
D. "The client's situation is extremely important. Has your circle of relatives made funeral
arrangements?" - ANS-A. "Your loved one's circumstance is very crucial, and there has been no
response in the remaining 24 hours"
,A sixty seven-12 months-vintage female who lives by myself tripped on a rug in her home and
fractured her proper hip. The nurse knows that which predisposing aspect contributes to the
incidence of hip fractures among elderly girls.
A. Urinary retention ensuing in renal calculi formation
B. Failing eyesight ensuing in an dangerous environment
C. Osteoporosis as a result of hormonal adjustments
D. Transient ischemic attacks (TIAs) which impair mental interest - ANS-C. Osteoporosis
attributable to hormonal adjustments
A 75-yr-old male customer with Alzheimer's Disease (AD) is admitted to an prolonged care
facility. What
intervention have to the nurse consist of into his customer's Nursing care plan?
A. Describe the activities to be had to the residents and inspire him to choose those he prefers
B. Introduce the client to the Nursing personnel and the residents as soon as viable
C. Plan to have the equal Nursing workforce offer take care of the customer on every occasion
possible
D. Encourage the consumer to remain at the unit for three weeks till he's orientated to his new
surroundings - ANS-C. Plan to have the identical Nursing body of workers offer care for the
customer whenever viable
A child with Chronic Asthma is scheduled for Chest Physiotherapy. When must the nurse
administer the meter-dosed inhalar (MDI) puff of bronchodilator relative to postural drainage
remedies?
A. Before postural drainage
B. During postural drainage
C. After postural drainage
D. Between treatements - ANS-C. After postural drainage
A consumer asks the nurse to provide an explanation for the vicinity of the prostate gland. What
is the satisfactory response?
A. Close the rectal wall the prostate gland sits in the back of the symphysis pubis extending
around the
starting of the urethra
B. At the lowest of the scrotal sac, the prostate gland rests under the testes, held in region by
using the
spermatic fascia
C. Attach to the the front and facets of the pubic arch, the prostate is a mess of cavernous
tissue held
collectively by way of fibrous tissue
D. Located at the lateral fringe of the posterior section of the testes, the prostate creates a bulge
continuous with the vas deferens - ANS-A. Close the rectal wall the prostate gland sits at the
back of the symphysis pubis extending around the
starting of the urethra
, A client at 28 weeks gestation is admitted to the antepartum unit and is being handled for
preterm hard work. She has a prescription for brethine (Terbutaline) 250 micrograms
subcutaneously q4h. The medication is to be had for injection in 1 mg in step with ML vials. How
many mL must the nurse administer?
A. Zero.1/2
B. 0.0025
C. Zero.25
D. 25.0 - ANS-C. Zero.25
A consumer starts offevolved an antidepressant drug at some point of the second day of
hospitalization. Which assessment is most important for the nurse to encompass in this
purchaser's plan of care even as the customer is taking the antidepressant?
A. Appetite
B. Mood
C. Withdrawl
D. Energy stage - ANS-B. Mood
A client involves the antepartal hospital and tells the nurse that she is 6 weeks pregnant. Which
signal is she most probable to document?
A. Decreased sexual libido
B. Amenorrhea
C. Quickening
D. Nocturia - ANS-B Amenorrhea
A patron complains of kidney pain. The nurse knows that the kidneys are positioned wherein?
A. On the retroperitoneal posterior stomach wall on the costovertebral angle
B. Within the curve of the duodenum, posterior to the spleen
C. Lateral to the stomach inside the hypochondriac location
D. Superior aspect of the bladder in proper and left iliac vicinity - ANS-A. On the retroperitoneal
posterior stomach wall at the costovertebral perspective
A customer has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for
pain control throughout the postoperative period following a lumber Laminectomy. What facts
need to the nurse improve about the movement of this adjuvant pain modality?
A. Mild electric stimulus at the skin floor closes the gates of nerve conduction for sever ache
B. Pain notion within the cerebral cortex is dulled via the unit's discharge of an electrical
stimulus
C. An infusion of medication in the spinal canal will block ache perception
D. The discharge of strength will distract the purchaser's cognizance on the pain - ANS-B. Pain
belief within the cerebral cortex is dulled through the unit's discharge of an electrical stimulus
A consumer has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medicine
drawer incorporates one 325mg aspirin. What movement have to the nurse take?
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