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Questions 149

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Question 1 of 5

A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

Correct Answer: D

Rationale: Serum alpha fetoprotein screening detects neural tube defects, such as spina bifida.

Question 2 of 5

A client with emphysema has been receiving oxygen at 3 L per minute by nasal cannula. The nurse knows that the goal of the client's oxygen therapy is achieved when the client's PaO2 reading is:

Correct Answer: B

Rationale: For clients with emphysema, a PaO2 of 70-80 mm Hg indicates adequate oxygenation without suppressing the respiratory drive.

Question 3 of 5

A 3-year-old child had a PPD skin test 2 days ago. When the mother brings the child back to the clinic to have the nurse check the results, the nurse notes a 10 mm area of induration. This is considered

Correct Answer: B

Rationale: A 10 mm induration 48-72 hours post-PPD is positive in children, indicating TB exposure, especially in high-risk groups.

Question 4 of 5

The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?

Correct Answer: C

Rationale: Wrapping the IV in gauze hides it from view, reducing the likelihood of the client pulling it out, while being less invasive than restraints or threats.

Question 5 of 5

A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The dysrhythmia most commonly seen during suctioning is:

Correct Answer: A

Rationale: Suctioning can stimulate the vagus nerve, leading to bradycardia due to parasympathetic activation.

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