A papular lesion is noted on the perineum of the laboring client.  Which initial action is most appropriate?

Report finding to the doctor

A client with a diagnosis of HPV for which of the following?

Vaginal cancer

The client seen in the family planning clinic tells the nurse that she has a painful lesion on the perineum. The nurse is aware that the most likely source of the lesion is:

Herpes

A client visiting a family planning clinic is suspected of having an STI. The most diagnostic test for treponema pallidum is: 

Flourescent treponemal antibody (FTA)

Which laboratory finding is associated with HELLP in the obstetric client?

Elevated hepatic enzymes

The nurse is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex?

The nurse place her thumb in the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer

Which medicaton should be used with caution in the obstretric client with diabetes?

Brethine

A multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ration and phosphatidyl glycerol level. The L/S ratio is 1:1. The nurses assessment of this data is:

The infant is at high risk for respiratory distress syndrome

Which laboratory finding is associated with HELLP syndrome in the obstretric patient?

Elevated hepatic enzymes

Which medication should be used with caution in the obstretric client with diabetes?

Brethine

The nurse is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex?

The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer

A multigravida is scheduled for an amniocentesis at 32 weeks gestatio to determine the L/S ration and phosphatidyl glycerol level. The L/S ratio is 1:1.  the nurse's assessment of this data is:

The infant is at high risk for respiratory distress syndrome

Which observation in the newborn of a mother who is alcohol dependent would require immediate nursing intervention?

Jitteriness

(sign of seizure in neonate)

The 57 year old male client has elected to have epidural anesthesia as the anesthetic during  a hernia repair. If the client is experiencing hypotension, the nurse would:

Administer O2 per nasal canula

A client has cancer of the pancreas. The nurse should be the most concerned with which nursing diagnosis?

Alteration in nutrition

The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

Daily measurement of abdominal girth

The client arrives in the ER after an MVA. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

Fluid volume deficit

(hypovolemic)

Which information obtained from the visit to a client with hemophilia would cause the most concern?

The client:

Likes to play contact sports

The nurse on oncology is caring for a client with a white blood count of 800, a platelet count of 150,000, and a RBC  count of 250, 000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take?

Provide the visitor with a mask/gown

The nurse is caring for the client admitted after trauma to the neck in an MVA. The client suddenly becomes unresponsive and pale, with a BP of 60 systolic. The initial nurse's action should be to:

Increase infusion of NS

Immediately following the removal of a chest tube, the nurse would:

Cover insertion site with a Vaseline gauze

Which snack seletion by a client with osteoporosis indicates that the client understands the dietary management of the disease?

A cup of yogurt

The elderly client with hypomagnesia is admitted to the unit with an order for Magesium Sulfate. Which action by the nurse indicates understanding of Magnesium Sulfate?

Measuring urinary output

(MgSO4 may cause oliguria)

The nurse is caring for a 10 year old client scheduled for surgery. The client's mother tells the nurse that her religion forbids blood transfusions. What nursing action is most appropriate?

Notify physician of mother's refusal

A client is admitted to the unit 3 hours after an injury with second degree burns to the face, neck, and head. The nurse would be most concerned with the client developing which of the following?

Laryngeal edema

The nurse is evaluating nutritional outcomes for an elderly client with anorexia. Which data best indicates that the plan of care is effective?

The client gains weight

The client is admitted following repair of a fractured femur with cast application. Which nursing assessment should be reported to the doctor?

Paresthesia of the toes

Which would be an expected finding during injection of dye with cardiac catherization?

Warmth in the extremity

Which action by the healthcare worker indicates a need for further teaching?

The nurse wears gloves to take vitals signs

The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client's ECT has been effective?

The client has a grand mal seizure

The 5 year old is being tested for pinworms. To collect a specimen for assessment of pinworms. the nurse should teach the mom to:

Examine the perineal area with a flashlight 2-3 hours after the child is asleep and collect any eggs on a clear tape

Which instruction should be given regarding the medication use to treat enterobiasis (pinworms)?

The entire family should be treated

Which client should be assigned to the pregnant licensed practical nurse?

The client who just returned after recieving a linear accelerator radiation therapy for lung cancer