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Questions 149

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Question 1 of 5

A client is 4 hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?

Correct Answer: C

Rationale: Right-sided weakness post-left carotid endarterectomy suggests a neurological deficit, possibly from stroke or hematoma, requiring immediate intervention.

Question 2 of 5

A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

Correct Answer: B

Rationale: A papular lesion on the perineum during labor could indicate an infectious process (e.g., herpes), so reporting it to the doctor is the most appropriate initial action.

Question 3 of 5

A labor and delivery nurse is caring for a client in active labor. The fetal monitor shows late decelerations. The nurse should first

Correct Answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency. The left lateral position improves placental perfusion, addressing the immediate cause.

Question 4 of 5

The nurse is caring for a client who is postoperative day 2 following a total knee replacement. The client reports pain at the surgical site and has a temperature of 100.8°F (38.2°C). Which of the following actions should the nurse take FIRST?

Correct Answer: D

Rationale: assessing the surgical site for signs of infection is the first step to determine the cause of the fever and pain

Question 5 of 5

A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:

Correct Answer: C

Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.

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