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Question 1 of 5

A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?

Correct Answer: C

Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.

Question 2 of 5

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following findings would indicate a complication of TPN therapy?

Correct Answer: B

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia, a common TPN complication due to high dextrose content, requiring insulin adjustment or rate change. Weight gain (
A) is expected, low-grade fever (
C) is nonspecific, and normal urine output (
D) is unremarkable.

Question 3 of 5

A nurse is teaching a patient about the use of albuterol (Proventil) for asthma. Which of the following instructions should be included?

Correct Answer: D

Rationale: Albuterol, a rescue inhaler, is used before exercise to prevent exercise-induced bronchospasm. It’s not for daily prevention, symptom-only use, or bedtime dosing.

Question 4 of 5

A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?

Correct Answer: D

Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.

Question 5 of 5

A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?

Correct Answer: B

Rationale: Male sexual abuse survivors may experience confusion about sexual identity, necessitating psychological support. The other statements are incorrect: long-term issues are common, not all survivors become abusers, and needs vary by gender. Psychosocial Integrity

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