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QUESTION NO: 1
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
A. Mother is concerned about her recovery.
B. Mother calls infant by name.
C. Mother lightly touches infant.
D. Mother is concerned about her weight gain.
Answer: B
Explanation:
(A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase.
QUESTION NO: 2
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:
A. Respiratory obstruction
B. Hypercalcemia
C. Fistula formation
D. Myxedema
Answer: A
Explanation:
(A)
Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy.
(B)
Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone.
QUESTION NO: 3
On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:
A. High Fowler
B. Lying on the left side
C. Sitting in a chair
D. Supine with feet elevated
Answer: A
Explanation:
(A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema.
QUESTION NO: 4
A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:
A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms
.
B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue.
C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend.
D. Respect the client's family's wishes.
Answer: D
Explanation:
(A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. (C) The nurse should leave the room and allow the family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs.
QUESTION NO: 5
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A. First trimester
B. Second trimester
C. Third trimester
D. Every trimester
Answer: A
Explanation:
(A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy.
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Updated: May 27, 2022