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Questions 158

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Question 1 of 5

A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:

Correct Answer: C

Rationale: Carbonated beverages increase gastric pressure, worsening hiatal hernia symptoms. Sleeping upright, small meals, and avoiding lying down post-meals are also recommended.

Question 2 of 5

An obstetrical client is admitted 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 condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.

Question 3 of 5

Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:

Correct Answer: D

Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.

Question 4 of 5

The client is diagnosed with a tension pneumothorax. Which intervention should the nurse anticipate?

Correct Answer: C

Rationale: Tension pneumothorax, a medical emergency, requires needle decompression to relieve pressure on the lung and mediastinum, followed by chest tube insertion. Oxygen and bronchodilators are secondary.

Question 5 of 5

The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:

Correct Answer: B

Rationale: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.

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