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Questions 158

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Question 1 of 5

A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?

Correct Answer: D

Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (
A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (
B) can worsen tissue damage. Changing pads (
C) prevents irritation but doesn’t directly improve perfusion.

Question 2 of 5

The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?

Correct Answer: B

Rationale: This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. This answer is incorrect. In testing memory, the nurse would attempt to get the client either to recall recent events or to think about past events.

Question 3 of 5

The nurse is caring for a client with a history of preterm labor. Which medication is most likely to be ordered to halt preterm contractions?

Correct Answer: B

Rationale: Nifedipine a calcium channel blocker is commonly used as a tocolytic to halt preterm contractions by relaxing uterine smooth muscle. Ritodrine is less used due to side effects magnesium sulfate is more for preeclampsia and indomethacin is used in specific cases.

Question 4 of 5

The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?

Correct Answer: C

Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.

Question 5 of 5

A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:

Correct Answer: B

Rationale: This statement represents a short-term goal. Long-term therapy should be directed toward assisting the client to cope effectively with stress. Suicide contracts represent short-term interventions. This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.

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