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Questions 149

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Question 1 of 5

A 52-year-old female had a hysterectomy 3 days ago and is recovering on the post-op floor. She is scheduled for an oral pain medication every 4 hours. She received her scheduled dose 1 hour ago but pushes the call light and complains of unrelenting and severe pain. The nurse should first

Correct Answer: D

Rationale: Severe, unrelenting pain post-hysterectomy suggests a complication (e.g., bleeding, infection). Notifying the physician for evaluation is the priority.

Question 2 of 5

The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?

Correct Answer: C

Rationale: Oatmeal, apple juice, and dry toast are low in sodium and saturated fat, aligning with a DASH diet for hypertension management.

Question 3 of 5

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Correct Answer: D

Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.

Question 4 of 5

After the physician performs an amniotomy, the nurse's first action should be to assess the:

Correct Answer: B

Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.

Question 5 of 5

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Correct Answer: C

Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.

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