Lenahsmith021

1. The nurse is caring for a patient who is in labor with her first child. The patient’s mother is present for support and notes that things have changed in the delivery room since she last gave birth in the early 1980s. Which current trend or intervention may the patient’s mother find most different? 1. Fetal monitoring throughout labor 2. Postpartum stay of 10 days 3. Expectant partner and family in operating room for cesarean birth 4. Hospital support for breastfeeding ANS: 4 Chapte...

CN 5 (Trigeminal) Motor – palpate over the masseter muscle as patient clenches jaw I will test the trigeminal nerve, which is cranial nerve number five. It has a motor component, and I will palpate Over the masseter muscle as you clench your jaw. And I don't feel any distortions, and you have great strength CN 5 (Trigeminal) Sensory – light touch sensation to forehead, cheeks, chin, nose (patient closes eyes) Now I am testing the sensory portion of the Trigeminal nerve, which is cranial...

A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a "bag of worms" in the left scrotum, superior to the testicles. Which of the following is most likely? A) Hydrocele of the spermatic cord B) Varicocele C) Testicular carcinoma D) A normal vas deferens Varicocle Varicoceles are common in normal men. They are often found in the left scrotum or bilaterally and should normally resolve in the supine position. This is be...

Your male patient complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action? – answer Deflate the balloon, advance the catheter further, then reinflate the balloon Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response? – Answer Respect his wishes and notify the provider Your patient is admitted with diverticulitis. What typ...

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? (ANS- Teach tracheal suctioning techniques In assessing an adult client with a partial rebreathe mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement? (ANS- Document the assessmen...

1. A male client with stomach cancer returns to the unit following a total gastrostomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the cl...

8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing. Correct Answer: D Assess for kinks or dependent loops in the tubing.

1. Which individual in a practical/vocational nursing class would be identified as a traditional adult learner? a. One who has been out of school for many years b. One who has children and grandchildren c. One who knows the routine of education d. One who is in his or her early 20s ANS: D Traditional adult learners are individuals who come to the educational program directly from high school or another program of study. They are usually in their late teens or early 20s. The learner who has...

2. Which nursing intervention is most important when caring for a client receiving the antimetabolite cytosine arabinoside (Arc-C) for chemotherapy? A) Hydrate the client with IV fluids before and after infusion. B) Assess the client for numbness and tingling of extremities. C) Inspect the client's oral mucosa for ulcerations. D) Monitor the client's urine pH for increased acidity. C) Inspect the client's oral mucosa for ulcerations. Cytosine arabinoside (Arc-C) affects the rapidly ...

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. 2. The nurse is assessing a healthy child at the 2 year checkup. Which of the following should the nurs...