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A．Inability to make choices and decisions without advice.
B．Showing interest only in solitary activities.
C．Avoiding developing relationships.
D．Recurrent self-destructive behavior with history of depression.

A．hearing loss.
B．vision changes.
C．decreased urine output.
D．gait instability.

A．ensuring adequate nutrition.
B．preventing infection.
C．promoting neural tube sac drainage.
D．conserving body heat.

A．decrease the possibility of absorption on the nurse's skin.
B．allow distribution of medication.
C．prevent soiling of the client's clothes.
D．avoid administering more than the prescribed dose.

A．Glucocorticoids.
B．Digoxin.
C．Antibiotics.
D．Anti-inflammatory medications.

A．Lack of thiamine.
B．Lack of vitamin C.
C．Lack of folate.
D．Lack of vitamin A.

A．Increased carboxyhemoglobin.
B．Decreased partial pressure of arterial oxygen (PaO₂).
C．Increased partial pressure of arterial carbon dioxide (PaCO₂).
D．Decreased bicarbonate (HCO₃^-).

A．"Now isn't a good time to begin dieting because you are eating for two. "
B．"Let's explore your feelings further. "
C．" Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems. "
D．"The prenatal vitamins should ensure the baby gets all the necessary nutrients. "

A．Tachycardia.
B．Warm, flushed extremities.
C．Parotid gland tenderness.
D．Coarse hair growth.

A．The family's ability to take care of the client's special diet needs.
B．The family's expectation that the client will resume responsibilities and role-related activities.
C．Emotional support from the family.
D．The family's ability to understand the ups and downs of the illness.

A．General health for the last 10 years.
B．Current health promotion activities.
C．Family history of diseases.
D．Marital status.

A．Elevating the head of the bed 45 to 90 degrees.
B．Auscultating the chest for adventitious sounds.
C．Obtaining a sputum specimen for culture.
D．Notifying the physician of the client's admission.

A．To reduce psychotic symptoms.
B．To reduce extrapyramidal symptoms.
C．To control nausea and vomiting.
D．To relieve anxiety.

A．below 70 mg/dL.
B．between 70 and 120 mg/dL.
C．between 120 and 180 mg/dL.
D．above 180 mg/dL.

A．Your hearing may not improve but you'll no longer be bothered by tinnitus.
B．Your hearing may be dramatically improved right after surgery.
C．You may notice improved hearing within 1 to 2 weeks.
D．Your hearing may improve 3 to 6 weeks after surgery.

A．"You need to lie down more during the day to get off your feet. "
B．"Avoid lifting heavy loads, and try using the pelvic tilt exercise. "
C．"Have others pick things up for you so you don't have to bend over so much. "
D．"Your back pain will go away after the baby is born. "

A．respiratory distress.
B．profound tachycardia.
C．signs of improved oxygenation.
D．diminished cyanosis.

A．Set up specific times to empty the bladder.
B．Force fluids.
C．Provide adequate roughage.
D．Encourage the use of an indwelling urinary catheter.

A．Partial thromboplastin time (PTT)   to 2 times the control.
B．Prothrombin time (PT)  to 2 times the control.
C．International normalized ratio (INR) of 3 to 4.
D．Hematocrit of 32%.

A．allowing the family to see a newly admitted client.
B．ambulating the client in the hallway.
C．administering pain medication.
D．placing wrist restraints on the client.

A．use a tampon after insertion to increase medication absorption.
B．release and pull up on the applicator before removal.
C．never refrigerate suppositories.
D．use only a water-soluble lubricant when inserting a suppository.

A．Semi-Fowler's with both legs flexed.
B．Legs adducted with head elevated.
C．Swaddled in a baby carrier.
D．Prone position with hips abducted.

A．"I should take corticosteroids on an empty stomach. "
B．"I need to take corticosteroids to help build up my immune system. "
C．"I should stop taking corticosteroids if I haven't had an asthma attack for 1 week. "
D．"I'll tell my other health care providers that I'm taking a corticosteroid. "

A．"Her physical development will be rapid at this stage, and rapid development will continue from now on. "
B．"She'll become more independent and won't require parental supervision. "
C．"Don't anticipate any changes at this stage in her growth and development. "
D．"Friends will be very important to her, and she'll develop an interest in the opposite sex. "

A．Establish IV access.
B．Assess fetal heart rate (FHR) and maternal blood pressure.
C．Prepare the client for a cesarean delivery.
D．Assess maternal heart rate and respiratory rate.

A．Check the neonate's blood pressure.
B．Check the specific gravity again as soon as possible.
C．Notify the physician.
D．Continue the ordered IV flow rate.

A．"Your baby will be fine. That's just superstition. "
B．"Don't worry. We'll make sure your baby is okay. "
C．"I can see that you are concerned. Let's talk about what's bothering you. "
D．"Perhaps so. Your baby should be seen by a physician as soon as it's born. "

A．Fetal scalp pH of 7.14.
B．Fetal heart rate (FHR) of 144 beats/minute.
C．Acceleration of FHR with contractions.
D．Long-term variability.

A．Insert the suction catheter while applying suction.
B．Apply suction until all the secretions have been removed.
C．Use the same catheter to first suction the mouth, then the endotraeheal tube.
D．Preoxygenate with 100% oxygen before suctioning.

A．leave the client and get help.
B．obtain a physician's order to restrain the client.
C．read the facility's policy on restraints.
D．order soft restraints from the storeroom.

A．reduces gastric solution production and hypermobility.
B．slows emptying of the stomach and reduces chyme in the duodenum.
C．inhibits contraction of the bile duct and gallbladder.
D．decreases bile secretions.

A．Encourage breas-feeding so that she can get her rest and get healthier.
B．Encourage breast-feeding because it's healthier for the neonate.
C．Encourage breast-feeding to facilitate bonding.
D．Discourage breast-feeding because HIV can be transmitted through breast milk.

A．30-year-old woman taking oral contraceptive pills.
B．45-year-old woman who has never been pregnant.
C．40-year-old woman with three children.
D．36-year-old woman who had her first child at age 22.

A．Awakening several times during the night to redose.
B．Respiratory rate of 10 breaths/minute.
C．Pain rating of 2 or 3 on a scale of 0 to 10.
D．Complaint of itching as an adverse effect of the analgesia.

A．Keep the affected leg in a position of adduction.
B．Use measures other than turning to prevent pressure ulcers.
C．Prevent internal rotation of the affected leg.
D．Keep the hip flexed by placing pillows under the client's knee.

A．One fingerbreadth above the umbilicus.
B．One fingerbreadth below the umbilicus.
C．At the level of the umbilicus.
D．Below the symphysis pubis.

A．Using crutches properly.
B．Exercising joints above and below the cast, as ordered.
C．Avoiding walking on a leg cast without the physician's permission.
D．Reporting signs of impaired circulation.

A．Assume he's anxious about discharge, and administer pain medication.
B．Assess the surgical site and affected extremity.
C．Reassure the client that pain is a direct result of increased activity.
D．Suspect a wound infection, and monitor the client's temperature and vital signs.

A．institutional resources.
B．standards of practice.
C．client-care quality.
D．nursing recruitment.

A．burning or tingling on the vulva, perineum, or vagina.
B．dysuria and urine retention.
C．perineal ulcers and erosions.
D．bilateral inguinal lymphadenopathy.

A．Using antibacterial soap when bathing clients with MRSＡ.
B．Conducting culture surveys periodically.
C．Ensuring that personnel wash their hands before and after contact with every client.
D．Using specific housekeeping practices for environmental cleaning.

A．Antibiotic therapy.
B．Pain management.
C．Blood transfusion.
D．Anticoagulation.

A．2 hours.
B．3 hours.
C．5 hours.
D．6 hours.

A．Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.
B．Store the drug in a cool, well-lit place.
C．Lie down or sit in a chair for 5 to 10 minutes after taking the drug.
D．Restrict alcohol intake to two drinks per day.

A．a depressed client.
B．a manic client.
C．a suicidal client.
D．an anxious client.

A．in the cheek.
B．on the tip of the tongue.
C．under the tongue.
D．under the lower lid of the eye.

A．10 gtt/min.
B．12 gtt/min.
C．19 gtt/min.
D．75 gtt/min.

A．Activity intolerance.
B．Impaired tissue integrity.
C．Impaired oral mucous membranes.
D．Ineffective tissue perfusion (cerebral, cardiopulmonary, GI).

A．turn the client every 2 hours.
B．elevate the head of the bed 30 degrees.
C．encourage increased fluid intake.
D．maintain a cool room temperature.

A．a first heart sound (S₁).
B．a third heart sound (S₃).
C．a fourth heart sound (S₄).
D．a murmur.

A．Bone fracture.
B．Loss of estrogen.
C．Negative calcium balance.
D．Dowager's hump.

A．A rigid abdomen.
B．A soft, nontender uterus.
C．Painful vaginal bleeding.
D．Hypotension.

A．This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.
B．The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
C．The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
D．The human papillomavirus (HPV), which causes condylomata aeuminata, can't be transmitted during oral sex.

A．Arranging pieces of furniture close together so the client can use them for guidance and support.
B．Encouraging the client to wear a medical identification bracelet that describes the client's visual deficit.
C．Installing a flashing light to indicate when the phone or doorbell is ringing.
D．Installing handrails in hallways, in bathrooms, and on steps.

A．Autonomy.
B．Initiative.
C．Industry.
D．Identity.

A．initiate a stream of urine.
B．breathe deeply.
C．turn to the side.
D．hold the labia or shaft of penis.

A．congenital deformity.
B．age.
C．trauma.
D．obesity.

A．inserting an indwelling urinary catheter.
B．giving a back rub on intact skin.
C．changing an oxygen system.
D．inserting an IV catheter.

A．neuromuscular function.
B．bowel sounds.
C．respiratory rate.
D．electrocardiogram (ECG) results.

A．Risk for fetal or maternal injury related to the crisis of childbearing.
B．Risk for infection related to suppressed immune status.
C．Risk for deficient fluid volume related to dehydration.
D．Risk for fetal injury related to uteroplacental insufficiency.

A．Teaching the client about the adverse effects.
B．Calling the physician and questioning the order.
C．Instituting dietary restrictions.
D．Taking baseline vital signs.

A．"Be careful after taking nitroglycerin because it may cause dizziness. "
B．"Make sure you replace your nitroglycerin tablets every 6 months to ensure potency. "
C．"A burning sensation after taking nitroglycerin indicates medication potency. "
D．"When you experience chest pain, take one tablet every 30 minutes until the pain is relieved. "

A．daily weight.
B．serum sodium levels.
C．measured intake and output.
D．blood pressure.

A．Distilled water.
B．Dextrose 5% in water (D5W) only.
C．DSW with 40 mEq of potassium chloride.
D．Dextrose 10% in saline.

A．Coma, anxiety, confusion, headache, and cool, moist skin.
B．Kussmaul's respirations, dry skin, hypotension, and bradycardia.
C．Polyuria, polydipsia, hypotension, and hypernatremia.
D．Polyuria, polydipsia, polyphagia, and weight loss.

A．"I've gained 3 pounds in the last month. "
B．"I eat loads of spinach and yellow vegetables each day. "
C．"I'm a perfectionist, and I work hard to get A's. "
D．"I binge frequently in the morning and feel fat. "

A．hypoglycemia.
B．fluid volume excess.
C．aspiration.
D．constipation.

A．teach children to cover mouths and noses when they sneeze.
B．have their children immunized against impetigo.
C．teach children the importance of proper hand washing.
D．isolate the child with impetigo from other members of the family.

A．inform the surgeon this isn't within her scope of practice.
B．report the surgeon to the Ethics Committee.
C．report the surgeon to the nursing supervisor.
D．follow the order as requested by the surgeon.

A．A stroke client with dysarthria.
B．An ambulatory client with Alzheimer's disease.
C．A 92-year-old client who needs help with activities of daily living (ADLs).
D．A client with severe, deforming rheumatoid arthritis.

A．Check the client's blood pressure.
B．Place the client in high Fowler's position.
C．Calculate the client's fluid balance.
D．Notify the physician.

A．Apply abdominal thrust.
B．Apply chest thrust.
C．Begin cardiopulmonary resuscitation (CPR).
D．Reposition the client on her side.

A．has a respiratory infection.
B．is intubated and on a ventilator.
C．has pleural chest tubes.
D．is receiving feedings through a jejunostomy tube.

A．Feelings of disbelief and ambivalence.
B．Feelings of clumsiness and "ugliness".
C．Increasing introspection but a general sense of well-being.
D．Anxiety about the labor and delivery experience.

A．The student discusses conflicts over drug use.
B．The student accepts a referral to a substance abuse counselor.
C．The student agrees to inform his parents of the problem.
D．The student reports increased comfort with making choices.

A．Hand washing.
B．Nasogastrie (NG) tube irrigation.
C．Colostomy irrigation.
D．IV catheter insertion.

A．Withdrawal.
B．Logical thinking.
C．Repression.
D．Denial.

A．Antidiuretic hormone (ADH).
B．Thyroid-stimulating hormone (TSH).
C．Follicle-stimulating hormone (FSH).
D．Luteinizing hormone (LH).

A．assess hand grip.
B．assess orientation to person, time, and place.
C．assess arm drifting.
D．assess gag reflex.

A．resume CPR beginning with breaths.
B．declare her efforts futile.
C．resume CPR beginning with chest compressions.
D．call for assistance.

A．The caregiver had a close relationship with the client before diagnosis of the illness.
B．The caregiver has no formal support, such as a visiting nurse or day care worker.
C．The caregiver understands the full reality of the disease and its inevitable progression.
D．The caregiver feels unable to control the client and unable to cope with caregiving.

A．Examine feet once per week for redness, blisters, and abrasions.
B．Apply lotion to dry feet, especially between the toes.
C．Avoid hot-water bottles and heating pads.
D．Dry feet vigorously after each bath.

A．Occupational therapist.
B．Physical therapist.
C．Recreational therapist.
D．Speech therapist.

A．"Tell me what your day will be like after you take your baby home. "
B．"Will anyone be available to help you at home with the baby?"
C．"Have you had any experience taking care of babies?"
D．"What are you planning to do with your baby when you return to school?"

A．Checking for the umbilical cord around the neonate's neck.
B．Placing antibiotic ointment in the neonate's eyes.
C．Turning the neonate's head to the side, to drain secretions.
D．Assessing the neonate for respirations.

A．Poor sleeping habits.
B．Lack of social support.
C．Adverse drug effects.
D．Presence of panic disorder.

A．Performing gentle passive range-of-motion (ROM) exercises.
B．Gently massaging the painful joints.
C．Using a bed cradle to keep linens off the joints.
D．Encouraging position changes in bed every 2 hours.

A．Meperidine (Demerol).
B．Oxytocin (Pitocin).
C．Promethazine (Phenergan).
D．Glycopyrrolate (Robinul).

A．the client is mentally ill.
B．the client refuses to give informed consent.
C．the client is in an emergency situation.
D．the client asks the nurse to give substituted consent.

A．Prominent nasal bridge.
B．Thick upper lip.
C．Upturned nose.
D．Large for gestational age.

A．The toddler stays neat while eating.
B．The toddler finishes the meal within a specified period of time.
C．The child lies down to rest after eating.
D．The child eats finger foods by himself.

A．Hyperglycemia.
B．Extreme hunger.
C．Hypotension.
D．Hypoglycemia.

A．Holding sterile objects above the waist.
B．Considering a 1" (2.5 cm) edge around the sterile field as being contaminated.
C．Pouring solution onto a sterile field cloth.
D．Opening the outermost flap of a sterile package away from the body.

A．Document it on their evaluation.
B．Ask them to attend inservice training for administration of IV medications.
C．Report them to the supervisor.
D．Report the incidents to the hospital attorney.

A．Lanugo.
B．Acroeyanosis.
C．Mongolian spots.
D．Hemangiomas.

A．External otitis is eharaeterized by pain when the pinna of the ear is pulled.
B．External otitis is usually accompanied by a high fever in children.
C．External otitis is usually related to an upper respiratory infection.
D．External otitis can be prevented by using cotton-tipped applicators to clean the ear.

A．12 hours.
B．20 hours.
C．24 hours.
D．50 hours.

A．whole blood and albumin.
B．platelets and packed red blood cells.
C．fresh frozen plasma and whole blood.
D．cryoprecipitate and fresh frozen plasma.

A．Follow a low-phenylalanine diet before trying to conceive.
B．A low-phenylalanine diet is necessary only during the first trimester.
C．Begin a low-phenylalanine diet when pregnancy is confirmed.
D．Dietary restrictions won't be necessary.

A．"Yes. Hypertension is prevalent among males; it's fortunate we caught this during your routine examination. "
B．"We'll need to reevaluate your blood pressure because your age places you at high risk for hypertension. "
C．"A single elevated blood pressure doesn't confirm hypertension. You'll need to have your blood pressure reassessed several times before a diagnosis can be made. "
D．"You have no need to worry. Your pressure is probably elevated because you're in the doctor's office. "

A．Total lung capacity.
B．Forced vital capacity.
C．Tidal volume.
D．Residual volume.

A．Infuse the medication quickly to minimize its irritating effect on the walls of blood vessels.
B．Obtain renal function tests, such as blood urea nitrogen (BUN) and creatinine levels, throughout the course of therapy.
C．Assess for pulmonary and peripheral edema.
D．Obtain an order for an antiemetic to counteract the common adverse effect of nausea.

A．perform chest physiotherapy every 4 hours.
B．give pancreatic enzymes as ordered.
C．place the child in an oxygen tent and have oxygen administered continuously.
D．serve a high-calorie diet.

A．altered perceptions.
B．toxic levels of pain medication.
C．impaired cognitive function.
D．impaired sense of time.

A．Eye structure and visual acuity changes.
B．Facial hair decreasing in a female client.
C．Facial hair increasing in a male client.
D．Wounds healing more quickly.

A．With a 4-year-old girl who has rheumatoid arthritis.
B．With a 5-year-old boy who is having a tonsillectomy.
C．With a 4-year-old girl who has leukemia.
D．Alone in a private room.

A．Arrange for her to return to school as soon as possible to promote psychosocial development.
B．Encourage her to engage in unrestricted physical activity to regain physical strength.
C．Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever.
D．Maintain seizure precautions, as central nervous system involvement may persist for several months.

A．Increased intestinal motility.
B．Decreased abdominal strength.
C．Increased intestinal bacteria.
D．Decreased production of hydrochloric acid.

A．Weight loss of 25%.
B．Birth weight of 2,000 to 2,500 g.
C．Weight loss then return to birth weight.
D．Weight gain of 25%.

A．tell him that she'll leave for now but will return soon.
B．ask him if it's okay if she sits quietly with him.
C．ask him why he wants to be left alone.
D．tell him that she won't let anything happen to him.

A．Administer antibiotics whenever the baby has a cold.
B．Place the baby in an upright position when giving a bottle.
C．Avoid getting the ears wet while bathing or swimming.
D．Clean the external ear canal daily.

A．Let the client eat alone to avoid embarrassment.
B．Weigh the client once a week in the same clothing.
C．Monitor the client for self-destructive tendencies.
D．Praise the client for "looking better" and remind the client that she isn't "too fat. "

A．Incentive spirometry.
B．Arterial blood gas (ABG) measurement.
C．Peak flow measurement.
D．Pulse oximetry.

A．prevents hepatitis infection in all people.
B．provides immunity for life.
C．must be administered within 2 weeks of exposure.
D．should be administered even if the person has anti-HAV antibodies.

A．Communicate by use of esophageal speech.
B．Improve body image and self-esteem.
C．Attain optimal levels of nutrition.
D．Maintain a patent airway.

A．70 units of NPH insulin and 30 units of regular insulin.
B．70 units of regular insulin and 30 units of NPH insulin.
C．70% NPH insulin and 30% regular insulin.
D．70% regular insulin and 30% NPH insulin.

A．apply suction to the NG tube every hour.
B．clamp the NG tube if the client complains of nausea.
C．irrigate the NG tube gently with normal saline solution.
D．reposition the NG tube if pulled out.

A．hypotension.
B．thick, coarse skin.
C．deposits of adipose tissue in the trunk and dorsocervical area.
D．weight gain in arms and legs.

A．give him privacy in the bathroom.
B．allow him to shave.
C．open the window and allow him to get some fresh air.
D．observe him.

A．Blood relationship.
B．Sex and size.
C．Compatible blood and tissue types.
D．Need.

A．Recent bed wetting.
B．Poor appetite.
C．Weight gain.
D．Boundless energy.

A．ask the client which activity he would prefer to do first.
B．negotiate a time when the client will perform activities.
C．tell the client specifically and concisely what needs to be done.
D．prepare the client ahead of time for the activity.

A．getting the client out of bed and into a chair for 30 minutes, twice daily.
B．avoiding repositioning the client if he's comfortable.
C．repositioning the client on alternate sides at least every 2 hours.
D．positioning the client with the greatest pressure at the bony prominence.

A．A 3-day-old neonate who has been fed IV since birth.
B．A 2-day-old neonate who has been breast-fed.
C．A 1-day-old neonate receiving formula.
D．A breast-fed neonate being discharged within 24 hours of birth.

A．delirium.
B．depression.
C．excessive drug use.
D．Alzheimer's disease.

A．avoid focusing on his weight.
B．increase his activity level.
C．follow a regular diet.
D．continue leading a high-stress lifestyle.

A．Client teaching about the cause of TB.
B．Reviewing the risk factors for TB.
C．Developing a list of people with whom the client has had contact.
D．Client teaching about the importance of TB testing.

A．an allergic reaction.
B．a myocardial infarction (MI).
C．a panic attack.
D．a hypoglycemic episode.

A．Explain to the client that the EFM shows mild contractions, so she should just relax and let the contractions work.
B．Take over as her coach because her husband isn’t helping her properly.
C．Ignore her reactions, realizing that this is her first time in labor and her reactions will soon match the intensity of contractions shown on the EFM.
D．Palpate her abdomen to determine the intensity of labor contractions as they’re taking place.

A．encourage the client to ask questions about personal sexuality.
B．provide time for privacy.
C．provide support for the spouse or significant other.
D．suggest referral to a sex counselor or other appropriate professional.

A．Autocratic.
B．Democratic.
C．Participative.
D．Laissez-faire.

A．Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes.
B．Flexor spasm, clonus, and negative Babinski’s reflex.
C．Blurred vision, intention tremor, and urinary hesitancy.
D．Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs.

A．Risk for imbalanced body temperature.
B．Decreased cardiac output.
C．Anxiety.
D．Acute pain.

A．Re-evaluate the fetal presentation.
B．Change the client’s position.
C．Offer a narcotic analgesic.
D．Help the client urinate.

A．Situational low self-esteem.
B．Unilateral neglect.
C．Social isolation.
D．Risk for loneliness.

A．the baby will need to fast before the test.
B．a sample of blood will be necessary.
C．a low-sodium diet is necessary for 24 hours before the test.
D．a low-intensity, painless electrical current is applied to the skin.

A．"I know I need to walk with a friend or family member. "
B．"I know I need to vary the times of day when I exercise. "
C．"I know I need to exercise before meals. "
D．"I know I need to drink fluids while I walk. "

A．Report her suspicions to the client’s physician.
B．Talk to the client about his attitude toward the medications.
C．Search the client’s room for evidence of the medications.
D．Tell the client that his behavior must stop for his own well-being.

A．Have her stop brushing her teeth until the gums heal.
B．Allow her to continue her routine of daily brushing.
C．Monitor her dental care and set limits on the amount of daily brushing.
D．Brush her teeth for her.

A．Tell the client’s spouse or partner to be supportive while she recovers.
B．Encourage the client to proceed with the next phase of treatment.
C．Recommend that the client remain cheerful for the sake of her children.
D．Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.

A．Maintain IV fluids at the present rate, and continue to reassess vital signs and urine output hourly.
B．Increase the IV rate, and continue to reassess vital signs and urine output hourly.
C．Decrease the IV rate, and continue to reassess vital signs and urine output hourly.
D．Administer a vasoconstrictor, and reassess vital signs and urine output hourly.

A．Lithotomy.
B．Supine.
C．Prone.
D．Lateral.

A．Partial thromboplastin time (PTT) to 2 times the control.
B．Prothrombin time (PT) to 2 times the control.
C．International normalized ratio (INR) of 3 to 4.
D．Hematocrit of 32%.

A．"I’m not permitted to discuss her progress. "
B．"I’ll give you the name and telephone number of her physician. "
C．"I’ll have her call you. "
D．"I can’t confirm whether your employee is a client here. "

A．limit oral fluid intake for 1 to 2 weeks.
B．report the presence of fine, sandlike particles through the nephrostomy tube.
C．notify the physician about cloudy or foul-smelling urine.
D．report bright pink urine within 24 hours after the procedure.

A．Disturbed thought processes.
B．Impaired adjustment.
C．Imbalanced nutrition. Less than body requirements.
D．Ineffective sexuality patterns.

A．congenital deformity.
B．age.
C．trauma.
D．obesity.

A．Check maternal blood pressure and pulse and fetal heart rate in response to contractions.
B．Realize that it’s too early to give pain medication, and encourage the husband to continue with the Lamaze coaching.
C．Arrange for a sonogram to determine fetal position.
D．Perform a vaginal examination to determine dilation, effacement, and station.

A．Determine the source of her anxiety and institute interventions to help her relax.
B．Immediately check the physician’s order and give her the analgesic ordered.
C．Inform her that the neonate’s head isn’t down far enough just yet but that, as soon as it is, medication will be given.
D．Tell her that her contractions are only moderately strong and that she should wait until later to take medication.

A．Weight gain of 30 lb (13.6 kg).
B．Maternal age of 32 years.
C．Blood pressure of 146/90 mmHg.
D．Treatment for syphilis at 15 weeks’ gestation.