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Questions 158

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Extract:


Question 1 of 5

A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting 15 seconds. The nurse interprets this test to be:

Correct Answer: B

Rationale: A reactive NST shows at least two accelerations of FHR (15 bpm, lasting 15 seconds) with fetal movements over 20 minutes, indicating fetal well-being.

Question 2 of 5

Endotracheal tube cuff pressure should never exceed:

Correct Answer: B

Rationale: Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion.

Question 3 of 5

A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

Correct Answer: D

Rationale: Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.

Question 4 of 5

Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?

Correct Answer: C

Rationale: Isoniazid can cause peripheral neuropathy by depleting vitamin B6 (pyridoxine), so supplemental pyridoxine is given to prevent this side effect.

Question 5 of 5

The nurse is caring for a client with a diagnosis of ectopic pregnancy. Which intervention is most appropriate?

Correct Answer: A

Rationale: Ectopic pregnancy requires surgical intervention (e.g. salpingectomy) or medical management (e.g. methotrexate) to remove the non-viable pregnancy.
Tocolytics fetal monitoring and antibiotics are not appropriate.

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