The nurse cares for a toddler diagnosed with immune thrombocytopenia purport. The child’s platelet count is 52,000/mm (52 x 10). The nurse prepares a care plan for the child. Which nursing diagnosis is most appropriate for this child? Fatigue related to elevated platelet count. Risk for injury related to low platelet count. Risk for activity intolerance related to need for rest. Impaired Physical mobility related to need for physical therapy. 2. The client takes heparin 12, 000 units daily by subcutaneous injection. Today’s aPTT level is 45 seconds. Which action does the nurse take first? Nothing as this is a normal a PTT level Notifies the health care provider to decrease the dosage. Changes the route from subcutaneous to intramuscular. Notifies the health care provider to increase the dosage. 3. The client is the single parent of the 2 week old baby, the firstborn child. The client had considered terminating the pregnancy but continued the pregnancy. There is little client family support. The client has a history of an editing disorder. The nurse knows which nursing diagnosis is most important for the client? Risk for impaired attachment related to lack of knowledge of child care. Situational Low Self-Esteem related to body changes of childbirth. Risk for ineffective coping related to postpartum depression. Disturbed sleep Pattern related to care of infant at night. 4.A nurse provides care for the newborn in the delivery area. The baby is breathing and crying well with good color. The nurse knows which priority is next? Prevent cold stress. Record Apgar. Initiate physical assessment. Begin bonding with parents. 5. The nurse care for the adolescent diagnosed with acquired aplastic anemia. The diagnosis is related to the practice of huffing substances with benzene. Which goal is the most important for this client during immunosuppression? Will have increased production of red blood cells. Will manage pain related to growth factor injections. Will cope with probability of death from disease. Will verbalize feelings about lack of bone marrow donor. 6. The nurse is preparing to insert an indwelling urinary catheter. Prioritize the order of steps.. From start to finish. All options must be used. Unordered options Lubricate tip of the catheter. Drape the client Insert the catheter Put on sterile gloves Cleanse the meatus 7.The nurse assesses the position of the fetus at the beginning of labor. The nurse feels the fetal occiput toward the left side of the pregnant clients sacrum. How does the nurse interpret thus finding? Right occiput anterior (ROA); fetus is currently in correct position for birth. Left sacrum anterior (LSA); fetus will need to flip end to end prior to birth. Left occiput transverse (LOT); fetus will turn head slightly prior to birth. Left occiput posterior (LOP); fetus will need to burn head prior to birth. 8. A client diagnosed with infective endocarditis is discharged home on IV antibiotic therapy. The nurse knows the client understands the discharge treatment plan when the client makes which statement? “when I get home, I can take of these compression stockings when I am walking.” “I can help care for my grandchildren when they are sick and stay home from school” “I can go back to my job next week and start back traveling” “I will tell my dentist about this illness before having my teeth cleaned.” 9. The client sustained a right hip fracture. The client had surgery to repair the hip. The nurse prepares for the client to return from surgery to the surgical unit. Which equipment is out important for the nurse to have available? Sandbags and pillows Walker and wheelchair Elevated toilet seat Continuous passive motion machine. 10. The nurse care for the 4 year old child. The parents report the child is irritable and has lost weight. The nurse assesses the child and discovers an irregular heart rate at 18- beats per minute and rest at 24 per min. Which does the nurse do first? Assesses the Childs temperature Notifies the health care provider Tells the parent the child has a heart disorder Asks the child if there is any chest pain 11. The nurse care for a client with as kin rash. The client scratches the rash and the skin starts to bleed. The nurse includes which nursing diagnosis in the clients plan of care? Ineffective health maintenance. Impaired skin integrity Impaired tissue integrity Risk for bleeding 12. A nurse in the clinic performs a pregnancy test and tells the couple they are pregnant. They are both excited and appear happy. At the next clinic visit, the client tells the nurse the partner is quiet and withdrawn although seeming initially happy at the news. Which is the best response by the nurse? When the pregnancy is more obvious, the partner will feel better. The changes in their life may be causing the partner anxiety The clients should be less enthusiastic around the partner The partner should seek psychiatric help for depression. 13. The Hospitalized client is scheduled for a paracentesis because of ascites. The nurse identifies which client goal related to the procedure? Client will have pain reduced from 10 to 8 Client will ave increased peripheral perfusion Client will understand reasons for the medication. Client will have bowel function return to normal. 14. A client reports indigestion that is not relieved with antacids. The client appears pale and ashen and the skin is cool and clammy. Which additional assessment data does the anticipate? (Select all that apply) Temperature above 102 F (38.9 C) Dyspnea Constipation and abdominal pain Extreme thirst and hunger Chest tightness Pain in the left arm and back 15. A client is 30 weeks pregnant. The delivery will be by cessarean birth due to a breech presentation. Which information does the nurse give the client regarding the delivery? (Select all that apply) Will have an IV started in the preoperative area. Will plan for epidural anesthesia Wil be given medication to relax prior to surgery Will have a full bowel prep Will be admitted the night before surgery Will have an indwelling urinary catheter inserted 16. The nurse obtains a specimen for arterial blood gasses from a client. Which principles guides the nurse? May use peripheral IV site if no IV fluids present Continuous intra arterial monitoring is required Air in the syringe will after the blood values Clotted blood will reserve the blood gas values 17. The client takes rifampin and isoniazid for turberculosis. The nurse knows the client understands the teaching about rifampin when which client statement is made? My urine may change color and become bluish.” “Because I have kidney disease, my dose is less than my spouse’s.” “I will need to have liver test done every week.” “I will take my medication 1 hour before I eat.” 18. A parent brings an infant client to the emergency department after the infant fell out of the high chair. The nurse assess the infant for a head injury. Which assessment data indicates the infant needs further testing? (select all that apply) Blurred vision Difficult to arouse from sleep Severe headache Difficulty speaking Bulging anterior fontanel Right eye pupil dilated 19. A psychiatrist nurse cares several clients with personally disorders. The nurse recognizes that clients diagnosed with narcissistic personality disorder exhibit which characteristic? (Select all that apply.) Exploitative habaviors Self-multilating behaviors Grandiosity Preoccupation with orderliness Hypersensitivity to criticism Attention seeking behavior. 20. The nurse presents a Program on Lyme disease. The nurse determines teaching is needed when a child makes which statement? “I will make sure I get the vaccination for lyme disease this spring” “if I get a tick bite, I will watch for a bullseye rash for up to 30 days”. “my dog has a new flea and tick collar, and I will check for ticks very day”. Insect repellent with DEET will help keep ticks from biting me”. 21. A client diagnosed with psoriasis is treated with etanercept. The nurse knows the client understands the disease and treatment when the client makes which statement. “I will stop the medication when I no longer have any symptoms.” “I Can apply this medication will cure the psoriasis.” “I am so glad this medication will cure the psoriasis”. “I will take this medication until I come to the clinic again” 22. The Nurse cares for the 13 year old child diagnosed with vesicoureteral reflux secondary to strictures caused by repeated bladder infections. The child receives continuous low dose antibiotics. The nurse assesses the compliance of treatment. Which questions does the nurse ask the child? (Select all that apply) “How much fluid do you drink each day” Are you active in any sports?” “how much sleep do you get at night?” “When do you take your medications”? “What foods do you like best and eat often?” “How often do you void during the day? 23. A client had a myocardial infarction. The nurse teaches the client to seek immediate treatment for which symptoms? (select all that apply) Shortness of breath with cough and nasal drainage. Jaw pain with dyspnea and dizziness. Heave its photophobia Chest pain with nausea and vommiting Abdominal pain with constipation Chest heaviness with pressure
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