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Question 1 of 5

A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:

Correct Answer: A

Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.

Question 2 of 5

The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?

Correct Answer: A

Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.

Question 3 of 5

Which information should be given to the client using a TENS unit?

Correct Answer: B

Rationale: Prolonged use of a TENS unit can cause skin irritation due to electrode adhesion or electrical stimulation. Electrocution is not a risk with battery-operated units, placement requires specific guidance, and lotions may interfere with electrode contact.

Question 4 of 5

Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?

Correct Answer: D

Rationale: Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose, indicating bleeding tendencies.

Question 5 of 5

The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

Correct Answer: C

Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (
A), wheezing (
B), and pain/rales (
D) are concerning but less urgent.

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