2 days after an abdominal hysterectomy, an elderly consumer with diabetes Mellitus Type II has
a syncopal episode. Her important signs are inside everyday limites and her sugar is 325
mg/dL. What intervention must the nurse put into effect first?
A. Give the consumer four ounces of orange juice
B. Administer subsequent scheduled dose of metformin (Glucophage)
C. Cancel the clients dinner tray
D. Administer regular insulin in step with sliding scale - ANS-D. Administer normal insulin in line
with sliding scale
36 hours after shipping, the nurse determines a customer's fundus is just above the umbilicus
and displaced to the right of midline. What action should the nurse take first?
A. Palpate the bladder for distention
B. Ask the purchaser when her ultimate bowel movement befell
C. Catheterize the client and file the amount
D. Assess the amount of lochia - ANS-A. Palpate the bladder for distention
four hours after management of 20U of regular insulin, the patron will become shake and
diaphoretic. What movement must the nurse take?
A. Encourage the consumer to excercise
B. Administer a PRN dose of 10U of everyday insulin
C. Give the customer crackers and milk
D. Record the patron's reaction on the diabetic float sheet - ANS-C. Give the patron crackers
and milk
A 26 year-old primigravida who added a 7-pound male little one 26 hours in the past tells the
nurse that she is pressured about whilst she and her husband can go back to having sexual
sex. What info must the nurse improve with this customer?
A. They may have intercourse when the episiotomy is healed and the lochial float has stopped
B. They ought to wait to renew sexual activities till the fatigue diverse with a brand new toddler
has surpassed
C. They can resume sexual interest at 6 weeks postpartum
D. It is high-quality to wait till both parties sense up to having sexual intercourse - ANS-A. They
can have sex when the episiotomy is healed and the lochial waft has stopped
A 26-year-old gravida four, para zero had a spontaneous abortion at nine weeks gestation. At
one-residence publish dilation and curettage (D&C) the nurse check the important signs and
symptoms and vaginal bleeding. The patron starts to cry softly. How must the nurse intrude?
A. Offer to name the social employee to talk about the possiblity of abortion
,B. Reassure the purchaser that the infertility expert can assist
C. Express sorrow for the customer's grief and provide to sit down along with her
D. Chart the critical signs and symptoms and amount of vaginal bleeding - ANS-C. Express
sorrow for the consumer's grief and offer to sit down along with her
A 3 12 months-old admitted with fever of unknown origin (FUO) has all started vomiting within
the past half hour. The toddler's temperature is 101.80 F, and the final dose of antipyretic
medication changed into given 5 hours ago. The child has prescriptions of acetaminophen
(Tylenol) one hundred sixty MG in line with five mL elixir or one hundred sixty mg suppositories
PRN fever or ache. What movement should 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 certain the kid's cooperation with swallowing
C. Notify the healthcare company that the kid's fever has become dangerously high
D. Use an acetaminophen suppository for the fever considering that the kid is vomiting - ANS-A.
Make the child NPO and keep all medications untill the vomiting has stopped
A 3-week-vintage infant is admitted for surgical repair of Pyloric Stenosis. What interventions
ought to the nurse assume to enforce to set up hydration in the instant postoperative duration?
A. Diaper weights and urin specific gravity
B. Gastronomy feedings in supine position
C. Nipple feedings with glucose water
D. Gavage feedings with 15mL of formula - ANS-C. Nipple feedings with glucose water
A 6-month antique male with Bronchiolitis is admitted to the health center. In monitoring the
respiration reputation of this child, which symptom shows the nurse that he's experiencing
Respiratory Distress?
A. Respiratory of 62 breaths/minute
B. Abdominal respiration
C. A high-pitched cry
D. Dry flushed pores and skin - ANS-C. A excessive-pitched cry
A 60 12 months-old purchaser with most cancers of the liver is in Hepatic Coma and
unresponsive. What have to the nurse say to family participants who're inquiring approximately
the circumstance of their cherished one?
A. "Your loved one's condition could be very essential, and there was no response in the closing
24 hours"
B. "The nurses have no longer been able to arouse the purchaser and the healthcare issuer is
aware of the outcome."
C. "You want to talk about the situation with the price nurse in a circle of relatives conference."
D. "The client's circumstance is extraordinarily vital. Has your family made funeral
arrangements?" - ANS-A. "Your loved one's condition could be very important, and there has
been no reaction within the last 24 hours"
,A sixty seven-yr-antique girl who lives on my own tripped on a rug in her domestic and fractured
her right hip. The nurse knows that which predisposing thing contributes to the incidence of hip
fractures among aged ladies.
A. Urinary retention ensuing in renal calculi formation
B. Failing eyesight ensuing in an risky environment
C. Osteoporosis due to hormonal modifications
D. Transient ischemic attacks (TIAs) which impair intellectual pastime - ANS-C. Osteoporosis
attributable to hormonal adjustments
A 75-yr-vintage male customer with Alzheimer's Disease (AD) is admitted to an extended care
facility. What
intervention need to the nurse include into his purchaser's Nursing care plan?
A. Describe the activities available to the citizens and encourage him to pick out the ones he
prefers
B. Introduce the purchaser to the Nursing team of workers and the residents as soon as feasible
C. Plan to have the equal Nursing group of workers provide take care of the consumer each
time possible
D. Encourage the purchaser to stay at the unit for three weeks till he is oriented to his new
surroundings - ANS-C. Plan to have the same Nursing team of workers offer care for the
purchaser on every occasion feasible
A infant with Chronic Asthma is scheduled for Chest Physiotherapy. When should the nurse
administer the meter-dosed inhalar (MDI) puff of bronchodilator relative to postural drainage
treatments?
A. Before postural drainage
B. During postural drainage
C. After postural drainage
D. Between treatements - ANS-C. After postural drainage
A client asks the nurse to give an explanation for the location of the prostate gland. What is the
first-rate reaction?
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 beneath the testes, held in location
by means of the
spermatic fascia
C. Attach to the the front and sides of the pubic arch, the prostate is a multitude of cavernous
tissue held
collectively by means of fibrous tissue
D. Located at the lateral fringe of the posterior phase of the testes, the prostate creates a bulge
non-stop with the vas deferens - ANS-A. Close the rectal wall the prostate gland sits at the back
of the symphysis pubis extending across the
, beginning of the urethra
A client at 28 weeks gestation is admitted to the antepartum unit and is being dealt with for
preterm hard work. She has a prescription for brethine (Terbutaline) 250 micrograms
subcutaneously q4h. The medicine is to be had for injection in 1 mg in step with ML vials. How
many mL have to the nurse administer?
A. Zero.1/2
B. Zero.0025
C. 0.25
D. 25.Zero - ANS-C. Zero.25
A patron starts an antidepressant drug throughout the second one day of hospitalization. Which
assessment is maximum crucial for the nurse to include on this patron's plan of care at the
same time as the consumer is taking the antidepressant?
A. Appetite
B. Mood
C. Withdrawl
D. Energy level - ANS-B. Mood
A client involves the antepartal health center and tells the nurse that she is 6 weeks pregnant.
Which sign is she maximum probably to file?
A. Decreased sexual libido
B. Amenorrhea
C. Quickening
D. Nocturia - ANS-B Amenorrhea
A client complains of kidney ache. The nurse knows that the kidneys are positioned where?
A. On the retroperitoneal posterior stomach wall at the costovertebral attitude
B. Within the curve of the duodenum, posterior to the spleen
C. Lateral to the belly inside the hypochondriac place
D. Superior aspect of the bladder in right and left iliac place - ANS-A. On the retroperitoneal
posterior abdominal wall on the costovertebral perspective
A consumer has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for
ache control for the duration of the postoperative period following a lumber Laminectomy. What
information must the nurse give a boost to approximately the action of this adjuvant pain
modality?
A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever
pain
B. Pain notion within the cerebral cortex is dulled by means of the unit's discharge of an
electrical stimulus
C. An infusion of medicine inside the spinal canal will block pain notion
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