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Questions 158

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Question 1 of 5

A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?

Correct Answer: B

Rationale: Supine position provides access to the sternum for bone marrow aspiration. Dorsal recumbent (
A) is for abdominal exams, High Fowler’s (
C) is for breathing, and lithotomy (
D) is for pelvic procedures.

Question 2 of 5

On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:

Correct Answer: C

Rationale: Leukoplakia cannot be rubbed off.

Question 3 of 5

The nurse is caring for a client with a history of a pulmonary embolism who is receiving Lovenox (enoxaparin). The nurse should monitor the client for:

Correct Answer: A

Rationale: Enoxaparin, a low-molecular-weight heparin, increases bleeding risk, requiring monitoring for signs like bruising or hematuria. Hypertension, tachypnea, and fever are not primary concerns.

Question 4 of 5

The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:

Correct Answer: A

Rationale: Normal ICP is 5-15 mmHg. A reading of 17 mmHg is elevated, indicating potential brain swelling, and requires immediate notification of the physician. The Glasgow scale complements but does not replace ICP monitoring.

Question 5 of 5

The client is admitted with a diagnosis of preterm labor. Which intervention is most appropriate?

Correct Answer: D

Rationale: In preterm labor betamethasone enhances fetal lung maturity tocolytics (e.g. nifedipine) halt contractions and fetal heart tone monitoring assesses fetal well-being. All interventions are appropriate.

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