Page 2577 - Saunders Comprehensive Review For NCLEX-RN

What is the nurse’s best response to the client? Refer to chart.

History and Physical Laboratory and Diagnostic Results Medications
Gravida, Term Births, Preterm Births, Abortions, Venereal Disease Research Prenatal
Living Children (GTPAL) 1,0,0,0,0 Laboratory (VDRL) nonreactive vitamins
Weight 135 lb (61 kg) Rubella immune
Positive Goodell and Chadwick Rh positive, type O

1. “You should avoid all school-age children during pregnancy.”
2. “There is no need to be concerned if you don’t have a fever or rash
within the next 2 days.”
3. “You were wise to call. Your rubella titer indicates that you are
immune and your baby is not at risk.”
4. “Be sure to tell the primary health care provider in 2 weeks, as
additional screening will be prescribed during your second
trimester.”
892. A breast-feeding mother of an infant with lactose intolerance asks the nurse
about dietary measures. What foods should the nurse tell the mother are
acceptable to consume while breast-feeding? Select all that apply.

1. 1% milk
2. Egg yolk

3. Dried beans

4. Hard cheeses

5. Green leafy vegetables
893. A client with diabetes mellitus is told that amputation of the leg is necessary
to sustain life. The client is very upset and tells the nurse, “This is all my
primary health care provider’s fault. I have done everything I’ve been asked
to do!” Which nursing interpretation is best for this situation?
1. An expected coping mechanism
2. An ineffective defense mechanism
3. A need to notify the hospital lawyer
4. An expression of guilt on the part of the client
894. A client with terminal cancer arrives at the emergency department dead on
arrival (DOA). After an autopsy is prescribed, the client’s family requests
that no autopsy be performed. Which response to the family is most
appropriate?
1. “The decision is made by the medical examiner.”
2. “An autopsy is mandatory for any client who is DOA.”
3. “I will contact the medical examiner regarding your request.”
4. “It is required by federal law. Tell me why you don’t want the
autopsy done.”
895. A client who is positive for human immunodeficiency virus (HIV) delivers a
newborn infant. The nurse provides instructions to help the client with care
of her infant. Which client statement indicates the need for further
instruction?

2577