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Questions 163

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Question 1 of 5

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?

Correct Answer: D

Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B,
C) are less specific.

Question 2 of 5

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP? Select all that apply.

Correct Answer: A,C,D

Rationale: Appropriate UAP tasks include elevating a leg , observing urine appearance , and reporting food intake . Measuring for stockings and verifying restraints require nursing judgment.

Question 3 of 5

A client who has congestive heart failure is being admitted. How should the nurse position this client?

Correct Answer: C

Rationale: Semi-sitting (Fowler's position) reduces cardiac workload and improves breathing in congestive heart failure by decreasing venous return.

Question 4 of 5

The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?

Correct Answer: D

Rationale: Ventricular septal defect. Surgical repair involves manipulation of the ventricular septum, increasing the risk of conduction disturbances.

Question 5 of 5

The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.

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