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Questions 149

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Question 1 of 5

A pregnant client is keeping a 'kick count' log during the last trimester. Which of the following may indicate fetal distress?

Correct Answer: C

Rationale: Fewer than 10 movements in 2 hours (
C) suggests fetal distress, as normal is >10 movements in 2 hours. Other options (A, B,
D) set incorrect thresholds.

Question 2 of 5

A woman has undergone a mastectomy of her right breast and has been brought to the recovery unit. The nurse explains that the client should

Correct Answer: A

Rationale: Elevating the arm on a pillow reduces lymphedema risk post-mastectomy by promoting lymphatic drainage.

Question 3 of 5

An RN delegates patient assignments to an LPN and nursing assistant. Later, the RN overhears a nursing assistant arguing with a patient regarding a late breakfast tray. The nursing assistant begins to raise his voice as the disagreement continues. The best action from the RN is

Correct Answer: A

Rationale: Addressing the nursing assistant privately de-escalates the situation, provides coaching, and maintains professionalism without immediate escalation.

Question 4 of 5

A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?

Correct Answer: B

Rationale: Trough levels measure the lowest drug concentration and are drawn just before a dose after steady-state, typically around the fourth dose for Gentamicin.

Question 5 of 5

The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet?

Correct Answer: C

Rationale: Cooked broccoli is high in fiber and should be avoided on a low-roughage diet for diverticulitis to prevent irritation.

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