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Questions 149

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Question 1 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 2 of 5

A client with pulmonary edema is ordered IV hydrocortisone (Solu-Cortef) 40 mg b.i.d. Which laboratory value would the nurse expect to see as a result of this therapy?

Correct Answer: C

Rationale: Hydrocortisone, a corticosteroid, increases blood glucose by promoting gluconeogenesis. Magnesium levels are not primarily affected.

Question 3 of 5

A 19-year-old female is admitted to the psychiatric floor after a suicide attempt 3 days ago. With client safety a priority, the nurse should

Correct Answer: A

Rationale: Placing the client near the nursing station allows close monitoring without isolation, balancing safety and autonomy. Constant staff presence is resource-intensive and not always necessary.

Question 4 of 5

The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?

Correct Answer: C

Rationale: Holding the breath during Davol drain removal prevents air entry into the pleural space, reducing the risk of pneumothorax.

Question 5 of 5

According to Maslow's hierarchy of needs, order the following needs from most basic to most advanced (bottom of the pyramid to the top):

Order the Items

Source Container

safety and security
esteem
physiological
love and belonging
self-actualization

Correct Answer: C,A,D,B,E

Rationale: Maslow’s hierarchy: physiological (most basic), safety and security, love and belonging, esteem, self-actualization (most advanced).

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