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Question 1 of 5

A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:

Correct Answer: A

Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.

Question 2 of 5

A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

Correct Answer: C

Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.

Question 3 of 5

Which toys are suited to the developmental skills of the 2-3 year old?

Question Image

Correct Answer: A, C, E

Rationale: For 2-3-year-olds, soap bubbles (
A), riding toys (
C), and talking toys (E) match gross motor and imaginative play skills. Skates (
B) and bicycles (
D) require advanced coordination.

Question 4 of 5

A client with Pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client's:

Correct Answer: B

Rationale: Pentamidine can cause hypotension, especially during IV administration, requiring close blood pressure monitoring. Reflexes, urine output, and turgor are less immediate concerns.

Question 5 of 5

The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:

Correct Answer: B

Rationale: The Whipple procedure (pancreaticoduodenectomy) is performed for cancer in the head of the pancreas, removing the head, duodenum, and other structures. Tail or body cancers require different surgeries.

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