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Question 1 of 5

A 52-year-old female with mitral valve stenosis is admitted to the floor. She asks the nurse why she got this condition because it does not run in her family. The nurse explains most cases of mitral stenosis are due to a history of

Correct Answer: C

Rationale: Rheumatic fever is the primary cause of mitral valve stenosis, leading to valve scarring years later.

Question 2 of 5

The nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?

Correct Answer: C

Rationale: Lack of light penetration during transillumination suggests fluid or pus in the sinuses, indicating a potential infection or obstruction.

Question 3 of 5

A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

Correct Answer: B

Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.

Question 4 of 5

The nurse is caring for a client receiving IV heparin therapy for a pulmonary embolism. Which lab values would the nurse expect to order on this client?

Correct Answer: C

Rationale: PT, PTT, and INR are monitored to assess the therapeutic effect and safety of heparin, which affects blood clotting.

Question 5 of 5

A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?

Correct Answer: C

Rationale: A weight gain of 6 pounds in a week suggests fluid retention, indicating possible overdosage of glucocorticoids, requiring adjustment.

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The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
The nurse is completing the preoperative checklist on a client scheduled for surgery and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?

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