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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Reduction of Risk Potential | 9-15% | - Reduction of Risk Potential
|
| Topic 2: Health Promotion and Maintenance | 6-12% | - Health Promotion and Maintenance
|
| Topic 3: Psychosocial Integrity | 6-12% | - Psychosocial Integrity
|
| Topic 4: Pharmacological and Parenteral Therapies | 13-19% | - Pharmacological and Parenteral Therapies
|
| Topic 5: Safety and Infection Control | 10-16% | - Safety and Infection Control
|
| Topic 6: Basic Care and Comfort | 6-12% | - Basic Care and Comfort
|
| Topic 7: Physiological Adaptation | 11-17% | - Physiological Adaptation
|
| Topic 8: Management of Care | 15-21% | - Management of Care
|
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NEW QUESTION # 201
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
Answer: B
Explanation:
Explanation
(A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
NEW QUESTION # 202
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:
Answer: A
Explanation:
Explanation
(A) Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such asKlebsiellapneumonia. (B) Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. (C) Green-colored sputum is more characteristic ofPseudomonasthan of gram-positive bacterial pneumonia. (D) Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
NEW QUESTION # 203
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. (B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. (C) This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. (D) If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
NEW QUESTION # 204
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will "beat out of her chest." The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. (B) The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. (C) Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. (D) The blood administration should take place over the ordered time frame designated by the physician.
NEW QUESTION # 205
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Answer: D
Explanation:
(A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
NEW QUESTION # 206
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