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Question 1 of 5

A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

Correct Answer: D

Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.

Question 2 of 5

When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

Correct Answer: C

Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.

Question 3 of 5

A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

Correct Answer: A

Rationale: In LOA, the fetus's back is on the mother's left anterior side, so fetal heart sounds are best heard below the umbilicus on the left.

Question 4 of 5

A client with a history of trigeminal neuralgia is admitted with complaints of facial pain. The nurse should give priority to:

Correct Answer: A

Rationale: Trigeminal neuralgia causes severe facial pain, so administering analgesics is the priority to relieve discomfort.

Question 5 of 5

The nurse is caring for a client with a history of anaphylaxis to peanuts. Which precaution is most important?

Correct Answer: A

Rationale: An epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Private rooms, antihistamines, and monitoring are secondary to ensuring rapid emergency response.

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