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Questions 148

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Question 1 of 5

A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?

Correct Answer: A

Rationale: A cervix dilated to 5 cm with 75% effacement indicates the active phase of labor.

Question 2 of 5

A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?

Correct Answer: C

Rationale: Simple signs help orient clients with Alzheimer's, reducing confusion and promoting independence in a new environment.

Question 3 of 5

A woman is receiving outpatient treatment at a mental health center. She starts crying and tells the nurse her husband has filed for divorce. The best response from the nurse is

Correct Answer: D

Rationale: An open-ended response like 'Tell me what happened' encourages the client to express feelings, fostering therapeutic communication.

Question 4 of 5

A 4-year-old girl has been transferred to a step-down recovery room after a tonsillectomy yesterday. The nurse should place the child in what position while she sleeps?

Correct Answer: D

Rationale: Side-lying position post-tonsillectomy promotes drainage of secretions, reducing airway obstruction risk.

Question 5 of 5

The nurse is performing fluid resuscitation on a burn client. Which piece of assessment data is the best indicator that it is effective?

Correct Answer: B

Rationale: Urine output of 30-50 mL/hr is the best indicator of adequate fluid resuscitation in burn clients, reflecting sufficient renal perfusion and fluid balance.

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