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Showing all 10 practice questions with expert explanatory rationales.
A client with a history of a tonsillectomy is being discharged. The nurse should teach the client to:
Expert Explanatory Rationale
Correct Answer: Report excessive swallowing
Excessive swallowing post-tonsillectomy may indicate bleeding, a serious complication requiring immediate reporting. Gargling, cold liquids, and straws may irritate the surgical site.
The client at 35 weeks gestation is admitted with a diagnosis of vasa previa. The nurse should monitor for which complication?
Expert Explanatory Rationale
Correct Answer: Fetal bleeding
Vasa previa involves fetal blood vessels crossing the cervical os risking rupture and fetal bleeding during labor or membrane rupture. Maternal hemorrhage preterm labor and macrosomia are less directly related.
The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?
Expert Explanatory Rationale
Correct Answer:
Elevated commode seats (A), removing rugs (B), grab bars (C), medic alert monitors (D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
Expert Explanatory Rationale
Correct Answer: All of the above
PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:
Expert Explanatory Rationale
Correct Answer: When the depression starts to lift
When the depression starts to lift, the client is able to make a workable plan, increasing the risk of suicide.
A client with a history of a gastrectomy is being taught about dietary management. The nurse should encourage the client to:
Expert Explanatory Rationale
Correct Answer: Eat six small meals a day
After a gastrectomy, eating six small meals a day prevents dumping syndrome by reducing gastric overload. Avoiding fluids with meals and taking vitamins are helpful, but small meals are primary.
The nurse is caring for a client in labor. The fetal heart rate is 80 bpm with moderate variability. The most appropriate initial action by the nurse is to:
Expert Explanatory Rationale
Correct Answer: Reposition the client to her left side
A fetal heart rate of 80 bpm indicates bradycardia possibly due to cord compression or uteroplacental insufficiency. Repositioning the client to her left side improves placental perfusion and is the first action. Oxygen notifying the physician or increasing fluids are secondary.
The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?
Expert Explanatory Rationale
Correct Answer: Hematuria
Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.
The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?
Expert Explanatory Rationale
Correct Answer: A client who is a diabetic with a foot ulcer
A diabetic with a foot ulcer is stable and suitable for an LPN, who can perform wound care and monitoring. Heparin infusion (B), tracheostomy weaning (C), and T-tube management (D) require RN-level skills due to complexity and risk.
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
Expert Explanatory Rationale
Correct Answer: To prevent or minimize separation anxiety
Favorite objects from home assist in creating a familiar setting, preventing or minimizing separation anxiety.
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