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Questions 163

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Question 1 of 5

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.

Correct Answer: B,C,D,E

Rationale: For shoulder dystocia: document timing for accuracy, flex legs for McRoberts maneuver, request help for additional support, and apply suprapubic pressure to dislodge the shoulder. Fundal massage is for postpartum hemorrhage.

Question 2 of 5

A woman is being seen in the physician's office for a medical complaint. When she is called to see the physician, she goes to the restroom and washes her hands over and over, missing her allotted time with the physician. How should the nurse deal with this woman?

Correct Answer: B

Rationale: Advance warning accommodates possible OCD, allowing hand washing within a timeframe, ensuring she sees the physician. Sending home, interrupting, or forcing choices is less effective.

Question 3 of 5

The nurse is auscultating the lungs in a postoperative client and hears something that sounds like a cellophane bag being wrinkled when the client takes in a breath. How should the nurse record this finding?

Correct Answer: A

Rationale: Crackles, sounding like crinkling cellophane, indicate fluid in alveoli or airway collapse, common post-surgery. Stridor, stertor, and wheezes have different characteristics.

Question 4 of 5

The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?

Correct Answer: A

Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.

Question 5 of 5

The client has contact dermatitis from poison ivy. Which statement, if made by the client, indicates that he understands how to care for his condition?

Correct Answer: C

Rationale: A cool wet cloth soothes itching and inflammation in contact dermatitis. Hot baths, strong soaps, or wool exacerbate irritation.

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