COMPLETE A+ Study Set Already Graded
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Delight Test Bank
,1. Post-Amniocentesis Monitoring (33 Weeks Gestation)
Question: A nurse is monitoring a pregnant client who is 33 weeks along and
has just undergone an amniocentesis. Which complication should the nurse be
most alert for?
• Correct Answer: D. Contractions
• Rationale: After an amniocentesis, uterine contractions can signal
preterm labor. Monitor for fetal distress and uterine activity closely.
2. Sleep Hygiene in Older Adults
Question: During a teaching session on sleep hygiene, which recommendation
should the nurse make to an older adult to support better nighttime sleep?
• Correct Answer: D. Eat a light snack before bedtime
• Rationale: Light snacks like crackers or warm milk promote melatonin
production and improve sleep quality.
3. Emergency Response to Ventricular Tachycardia
Question: A client on a telemetry unit becomes unresponsive with a monitor
showing ventricular tachycardia and no pulse. What should the nurse do first?
• Correct Answer: B. Defibrillate
, • Rationale: Immediate defibrillation is the priority to restore a viable
rhythm in pulseless V-tach according to ACLS protocols.
4. Language Barrier in Postpartum Admission
Question: A postpartum client reports heavy vaginal bleeding but does not
speak the nurse's language. What is the most appropriate action to gather
health information?
• Correct Answer: C. Request a female interpreter through the facility
• Rationale: A trained interpreter ensures confidentiality and accuracy
during medical communication.
5. Adverse Reaction to Cooling Blanket
Question: A febrile client is being treated with a cooling blanket. Which sign
indicates an adverse effect of this intervention?
• Correct Answer: D. Shivering
• Rationale: Shivering increases metabolic demand and body temperature,
counteracting the cooling effect.
, 6. DVT and Heparin Therapy Decision-Making
Question: A nurse is treating a client with a DVT in the left leg. Which action is
most appropriate based on a PTT of 30 seconds?
• Correct Answer: B. Withhold heparin IV infusion
• Rationale: A PTT of 30 seconds is below the therapeutic range for
heparin (typically 60–80 seconds); holding the medication is warranted.
7. Nutrition Referral Indication
Question: For which client scenario should the nurse initiate a referral to a
dietitian?
• Correct Answer: B. A client with a nonhealing leg ulcer
• Rationale: Chronic wounds require sufficient nutrition, especially
protein, for proper healing.
8. Discharge Education for Hemodialysis Client
Question: What dietary advice should the nurse give a client with chronic
kidney disease receiving hemodialysis?
• Correct Answer: A. Eat 1 g/kg of protein per day
• Rationale: This protein intake helps prevent muscle wasting while
accommodating renal function limitations.