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Questions 158

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Question 1 of 5

A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

Correct Answer: D

Rationale: Contractions five minutes apart lasting 30-60 seconds indicate the onset of active labor. Two-minute contractions suggest advanced labor and back pain or urination are less specific signs.

Question 2 of 5

The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be reported to the physician immediately?

Correct Answer: A

Rationale: Hyperkalemia (7.5 mEq/L) is life-threatening, risking arrhythmias, and requires immediate reporting. Hyponatremia (
B), slightly low pH (
C), and elevated hematocrit (
D) are less urgent in early burn care.

Question 3 of 5

A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?

Correct Answer: C

Rationale: This description is characteristic of the 'tension-building' phase prior to the volatile discharge of tension found in the battering phase.

Question 4 of 5

The client is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). Which intervention should the nurse anticipate?

Correct Answer: A

Rationale: ARDS causes severe hypoxemia, often requiring mechanical ventilation to maintain oxygenation. Nebulizers, physiotherapy, and antibiotics are secondary or condition-specific.

Question 5 of 5

MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:

Correct Answer: B

Rationale: An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. An anticonvulsant effect and vasodilation are the desired outcomes when administering this drug. An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4 is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment.

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