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Questions 148

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Question 1 of 5

A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

Correct Answer: A

Rationale: abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency

Question 2 of 5

A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?

Correct Answer: D

Rationale: Pain (
D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (
A), vital signs (
B), and oxygen saturation (
C) are secondary.

Question 3 of 5

The nurse is assessing a client for tactile fremitus. Which client would most likely exhibit a decrease in tactile fremitus? A client with:

Correct Answer: A

Rationale: Emphysema causes air trapping and hyperinflation, reducing tactile fremitus due to decreased transmission of vocal vibrations through the lungs.

Question 4 of 5

A client has ataxia following a cerebral vascular accident. The nurse should:

Correct Answer: A

Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.

Question 5 of 5

The client presents to the emergency room with a hyphema. Which action by the nurse would be best?

Correct Answer: A

Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.

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