WITH AUTHENTIC QUESTIONS, MASTER
NOTES, AND VERIFIED SOLUTIONS
◍ A client presents to the labor and delivery unit with a report of leaking
fluid that is greenish-brown vaginal discharge. Which action should the
nurse take first?
A. Start an intravenous infusion
B. Administer oxygen via facemask
C. Perform a vaginal exam
D. Begin continuous fetal monitoring Answer: D. Begin continuous fetal
monitoring
◍ A client asks the nurse for information about how to reduce risk
factors for benign prostatic hyperplasia (BPH). Which information
should the nurse provide?
A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test Answer: B.
Increase physical activity
,◍ The healthcare provider prescribes a fluid challenge of 0.9% sodium
chloride 1,000 mL to be infused intravenously over 4 hours. The IV
administration set delivers 10gtt/mL. How many gtt/minute should the
nurse regulate the infusion? (Round to the nearest whole number)
Answer: 42 gtt/min
◍ Following a cardiac catheterization and placement of a stent in the
right coronary artery, the nurse administers prasugrel, a platelet inhibitor,
to the client. To monitor for adverse effects from the medication, which
assessment is most important for the nurse to include in this client's plan
of care?
A. observe color of urine
B. Measure body temperature
C. Assess skin turgor
D. Check for pedal edema Answer: A. Observe color of urine
◍ A client fell in the bathroom when left unattended by the unlicensed
assistive personnel (UAP). Which information should the nurse include
in the client's health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip Answer: D. The
client fell sustaining a fracture to the left hip
,◍ The nurse is reviewing the diagnostic tests prescribed for a client with
a positive skin test. Which subjective findings reported by the client
supports the diagnosis of tuberculosis?
A. Barking cough and vomiting
B. Mucopurulent cough and night sweats
C. Dry cough and chest tightness
D. Chronic cough and fatty stools Answer: B. Mucopurulent cough and
night sweats
◍ In assessing a client with type 1 diabetes mellitus, the nurse notes that
the client's respirations have changed from 16 breaths/min with a normal
depth to 32 breaths/min and deep, and the client become lethargic.
Which assessment data should the nurse obtain next?
A. Temperature
B. Breath sounds
C. Blood glucose
D. White blood cell count Answer: C. Blood glucose
◍ A nurse receives report on a client who is four hours post-total
abdominal hysterectomy. The previous nurse reports that it was
necessary to change the client's perineal pad hourly and that it is again
saturated. The previous nurse also reports that the client's urinary output
has decreased. Which action should the nurse implement first?
A. Evaluate the skin turgor
B. Assess for weakness or dizziness
, C. Change the perineal pad
D. Measure the urinary output Answer: B. Assess for weakness or
dizziness
◍ The father of a 4-year-old has been battling metastatic lung cancer for
the past 2 years. After discussing the remaining options with his
healthcare provider, the client requests that all treatment stop and that no
heroic measures be taken to save his life. When the client is transferred
to the palliative care unit, which action is most important for the nurse
working on the palliative care unit to take in facilitating continuity of
care?
A. Reassure the client that his child will be allowed to visit
B. Provide the client written information about end-of-life care
C. Obtain a detailed report from the nurse transferring the client
D. Mark the chart with client's request for no heroic measures Answer:
C. Obtain a detailed report from the nurse transferring the client
◍ While assessing a client who is admitted with heart failure and
pulmonary edema, the nurse identifies dependent peripheral edema, an
irregular heart rate, and a persistent cough that produces pink blood-
tinged sputum. After initiating continuous telemetry and positioning the
client, which intervention should the nurse implement?
A. Obtain sputum sample
B. Document degree of edema
C. Initiate hourly urine output measurement