ANSWERS. // GRADED A+. // LATEST 2024/2025
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A nurse provides home care instructions to a client who has been fitted with a
halo device to treat a cervical fracture. Which statement by the client indicates
the need for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to prevent sweating
d. I have to check the pin sites everyday and watch for signs of infection -
ANS✔✔-C
Cleanse the skin under the wool liner each day to prevent rashes and soars.
A nurse is caring for a client with increased intracranial pressure. In which
position should the nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees - ANS✔✔-D
Proper positioning promotes venous drainage from the cranium to minimize ICP.
A client with a basilar skull fracture has clear fluid leaking from the ears. The
nurse should take which action first?
a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
,c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture - ANS✔✔-B
CSF contains glucose not protein.
A nurse provides information to a pregnant client about foods that are high in
iron. Which food, suggested by the client after this discussion, indicates that the
client requires further instruction?
Spinach
Tomatoes
Lima beans
Whole-grain bread - ANS✔✔-B
A nurse is assessing a client during her first prenatal visit to the clinic. The nurse
takes the client's temperature: 100.8°F (38.2°C). Which of the following actions
on the part of the nurse is appropriate?
Documenting the temperature
Retaking the temperature rectally
Notifying the primary health care provider
Informing the client that a temperature of 100.8°F is normal during pregnancy -
ANS✔✔-C
A client who is 8 weeks pregnant reads her electronic medical record via a
patient portal. She contacts the clinic and asks the nurse to explain a "positive
Hegar sign." Which is the best answer for the nurse to provide?
"You are able to feel fetal movement."
"A soft blowing sound can be heard with a stethoscope."
"The lower part of your uterus is softer than when you are not pregnant."
"You are experiencing irregular painless contractions during the pregnancy." -
ANS✔✔-C
Softening and compressibility of the lower uterine segment, occurring around the
sixth week of pregnancy, is called the Hegar sign.
A nurse has provided dietary instructions to a pregnant client with diabetes
mellitus. Which patient statement indicates the patient understands the
teaching?
, "I should increase my fat intake to ensure that the baby gains weight."
"I'll need to start a high-protein, high-fat diet to help control the blood glucose
level."
"I should add extra glucose to the diet because additional calories are needed
during pregnancy."
"I will need to increase fiber in the diet to help control the blood glucose level
and prevent constipation." - ANS✔✔-D
A nurse is performing an initial assessment of a pregnant adolescent client with
diabetes mellitus. The client says to the nurse, "I've stopped my insulin and cut
back on my food." Which client concern does the nurse recognize as the priority?
Concern about nutritional deficiency
Concern about getting stretch marks
Concern about being able to care for the infant
Concern about what her friends might think about her wearing maternity clothes
- ANS✔✔-A
A nurse is caring for a client who has just undergone cardioversion. Which
intervention is the nurse's priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client's LOC - ANS✔✔-A
ABC's of nursing. All other choices are correct, but not priority.
A client with diabetes mellitus who is scheduled to have blood drawn for
determination of the glycosylated hemoglobin (HbA1c) level asks the nurse why
the test is necessary if he is performing blood glucose monitoring at home.
Which is the best response for the nurse to provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct - ANS✔✔-B