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Questions 158

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Question 1 of 5

A client requires log rolling after back surgery. Correctly provide the sequence of steps the nurse should follow when performing the procedure.

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

Rationale: Log rolling sequence: Obtain assistance (
A), position nurses (
C), designate leader (
D), instruct arm placement (G), place pillow (E), align with pillows (
B), move coordinately (F).

Question 2 of 5

The nurse is performing an assessment on a client with a suspected diagnosis of cataracts. The chief complaint is likely to be:

Correct Answer: B

Rationale: Cataracts cause cloudy or blurry vision due to lens opacity. Eye pain, flashing lights, and redness are more associated with other conditions like glaucoma or retinal issues.

Question 3 of 5

Which finding is considered a risk factor in the development of leukemia?

Correct Answer: C

Rationale: Radiation exposure such as from treatment for Hodgkin’s lymphoma is a known risk factor for leukemia. Stamp collecting computer programming and a family history of stomach cancer are not established risk factors.

Question 4 of 5

The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?

Correct Answer: A

Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.

Question 5 of 5

The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

Correct Answer: C

Rationale: Early decelerations are reassuring and do not warrant notification of the physician. Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.

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