Nurse Moose
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    Exam Review

    1. A client who is in labor states, "I think my water just broke?" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
      A)Notify the operating room team.
      B)Administer a fluid bolus of 500 mL.
      C)Place the client in Trendelenburg.
      D)Administer oxygen via face mask.
    2. A primigravida client at 32-weeks gestation presents to the clinic with a report of a pounding headache. The client demonstrates hyperreflexia. The nurse should recognize the client's symptoms may be caused by which condition?
      A)Cerebral edema.
      B)Severe anxiety.
      C)Intravascular coagulation.
      D)Retinal arteriolar spasms.
    3. Patient Data Exhibits The nurse has mixed the formula with enteral nutritional formula powder to increase the caloric content to 24 calories per ounce (24 cal/30 mL).Which nursing intervention(s) should the nurse include from the plan of care to help meet the client's nutritional needs? Select all that apply.(SATA)
      A)Slowly increase caloric content using enteral nutritional formula powder.
      B)Feed the infant on demand.
      C)Make sure the infant is well rested before feeds.
      D)Wake the infant up to eat.
      E)Stroke the cheek to encourage sucking.
      F)Initiate a three-hour feeding schedule.
      G)Feed for one-hour duration.
      H)Give gavage feedings via percutaneous endoscopic gastrostomy (PEG) tube.
    4. A 14-year-old female client comes into the clinic for an annual exam and expresses concern about not starting her menstrual cycle. Which finding should the nurse recognize as potential cause of delayed menstration? Reference Range: Hemoglobin [10 to 15.5 g/dL (100 to 155 g/L)]
      A)Family history of breast cancer.
      B)Tanner stage 2 of breast development.
      C)Hemoglobin of 10 g/dL (100 g/L).
      D)Low body mass index (BMI).
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    Exam Review

    1. The nurse is caring for an infant with tetralogy of Fallot. During a blood draw the nurse observes the infant becoming pale and lethargic with circumoral cyanosis and diminished peripheral pulses. Which action should the nurse take next?
      A)Situate in knee-chest position.
      B)Perform chest physiotherapy.
      C)Reduce flow rate of intravenous fluid replacement.
      D)Administer prescribed morphine subcutaneously.
    2. The nurse is developing a teaching plan for a school-aged child with AIDS. Which instruction should the nurse include in the teaching plan for the family of a school-aged child with AIDS?
      A)Obtain a booster for all immunizations as soon as possible.
      B)Obtain an injection of penicillin G 1000 units weekly.
      C)Keep the child away from other children and begin a home school program.
      D)Avoid exposure to chickenpox.
    3. How many mL of urine output should the nurse document for an infant's wet diaper weight of 85 grams compared to the dry diaper weight of 50 grams? (Enter numeric value only.)
    4. The nurse is caring for a multiparous client who is in labor and observes a fetal heart rate (FHR) that decreases with the peak of a contraction and returns to baseline in 30 seconds. Which action should the nurse implement?
      A)Turn the client to her side.
      B)Perform a sterile vaginal exam.
      C)Administer oxygen via facemask
      D)Call the healthcare provider (HCP)
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    Exam Review

    1. When inspecting the ears of a toddler without the use of an otoscope, which action should the nurse take?
      A)Note location of the pinna in relation to the eye.
      B)Pull the pinna up and back during visualization.
      C)Examine the tympanic membrane for swelling.
      D)Observe color and appearance of ear drum.
    2. A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish brown. Which intervention should the nurse implement first?
      A)Contact the healthcare provider.
      B)Assess the fetal heart rate (FHR).
      C)Check the cervical dilation.
      D)Turn the client to her left side.
    3. A woman who delivered a 9 pound (4082 gram) baby boy by cesarean section (C-section) under spinal anesthesia is recovering in the postanesthesia care unit (PACU). Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina is observed by the nurse. Which action should the nurse implement?
      A)Let the infant breast feed.
      B)Assess her blood pressure.
      C)Massage the fundus vigorously.
      D)Apply ice pack to perineum.
    4. When obtaining an adolescent's health history, which intervention is most important of the nurse to implement?
      A)Assess for the use of illicit drugs.
      B)Evaluate vital signs and lab findings.
      C)Ask the parents to leave the room.
      D)Obtain a smoking history first.
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    Exam Review

    1. At 6-weeks gestation, the rubella titer of a client indicates she is nonimmune. When is the best time to administer a rubella vaccine to this client?
      A)Immediately, at 6-weeks gestation, to protect this fetus.
      B)After the client reaches 20-weeks gestation.
      C)After the client stops breastfeeding.
      D)Early postpartum, within 72 hours of delivery.
    2. Patient Data Exhibits The nurse is reviewing the client's admission information. Which signs or symptoms warrant immediate follow-up by the nurse? Select all that apply.(SATA)
      A)Bulging tympanic membranes
      B)Pain rating of 5 using FLACC scale
      C)Refusal of bottle
      D)Temperature: 101° F (38.3° C)
      E)Agitation while collecting vital signs
      F)Use of pacifier
      G)Heart rate of 188 beats/minute
      H)Respirations: 56 breaths/minute
      I)Warm, pale skin
    3. Patient Data Exhibits The nurse is considering the client's acute condition while performing the admission assessment. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse determines that the client's symptoms are most likely caused by ▾ Cleft palate resulting in ▾ Otitis media and ▾ Occluded eustachian tubes.
      Dropdown 1:
      Option 1: Cleft palate
      Option 2: Subglottic stenosis
      Option 3: Congenital laryngeal web
      Dropdown 2:
      Option 1: Hearing impairment
      Option 2: Otitis media
      Option 3: Nasal regurgitation
      Dropdown 3:
      Option 1: Speech delays
      Option 2: Poor weight gain
      Option 3: Occluded eustachian tubes
    4. Patient Data Exhibits The nurse is prioritizing care for the client. Select the 3 highest priority findings for the nurse to address.(SATA)
      A)Temperature
      B)Refusing bottle
      C)Signs of pain
      D)Cough during feeding
      E)Oxygen saturation
      F)Formula coming from nares
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    Exam Review

    1. Patient Data Exhibits The nurse is planning care for the client. Drag from Word Choices to complete the sentence. The nurse is planning interventions to reduce the client's risk of ▾ Aspiration, ▾ Pneumonia and ▾ Hearing loss.
      Dropdown 1:
      Option 1: Aspiration
      Option 2: Pneumonia
      Option 3: Cognitive delay
      Option 4: Poor vision
      Option 5: Hearing loss
      Dropdown 2:
      Option 1: Aspiration
      Option 2: Pneumonia
      Option 3: Cognitive delay
      Option 4: Poor vision
      Option 5: Hearing loss
      Dropdown 3:
      Option 1: Aspiration
      Option 2: Pneumonia
      Option 3: Cognitive delay
      Option 4: Poor vision
      Option 5: Hearing loss
    2. Patient Data Exhibits The nurse is considering appropriate education for the client's new diagnosis. Choose the most likely option for the information missing from the statement by selecting from the list of options provided. The nurse teaches the parents about decreasing the risk of aspiration when feeding by ▾ Interrupting feeding if the infant raises their eyebrows.
      Dropdown 1:
      Option 1: Interrupting feeding if the infant raises their eyebrows
      Option 2: Waiting until the end of each feeding to burp
      Option 3: Placing the infant in a reclining position at 45 degrees
    3. Patient Data Exhibits The nurse is evaluating the infant's progress and the parents' understanding of the condition. For each finding, click to indicate if it supports the interventions were effective or does not support the interventions were effective.
      Supports EffectivenessDoes Not Support Effectiveness
      Parents report infant can choke✓
      Infant refused bottle after 15 mL✓
      Parents requested nurse feed infant✓
      Respirations 38 breaths/minute✓
      Infant fell asleep after feeding✓
      Infant temperature 98.6° F (37.0° C)✓
    4. The healthcare provider (HCP) prescribes amoxicillin 500 mg PO every 8 hours for a child who weighs 77 pounds. The available suspension is labeled, "Amoxicillin Suspension 250 mg/5 mL. The recommended maximum dose is 50 mg/kg/24 hour. How many mL should the nurse administer in a single dose based on the child's weight? (Enter the numerical value only. If rounding is required, round to the whole number.)
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