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Questions 163

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Extract:


Question 1 of 5

An adult woman who has multiple sclerosis (MS) asks the nurse why she developed multiple sclerosis. What information should the nurse include when responding?

Correct Answer: B

Rationale: Multiple sclerosis is an autoimmune disorder where the immune system attacks myelin in the central nervous system, unlike infections or mosquito bites.

Extract:

Vital signs
Temperature 100.9 F (38.3 C)
Blood pressure 125/75 mm Hg
Heart rate 109/min
Respirations 15/min
SpO2 100%


Question 2 of 5

The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?

Correct Answer: B

Rationale: Postpartum endometritis requires prompt antibiotic treatment, so clindamycin IV is the priority to address the infection. Acetaminophen , fluids , and methylergonovine are supportive or unrelated.

Extract:


Question 3 of 5

The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?

Correct Answer: B

Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.

Question 4 of 5

While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?

Correct Answer: B

Rationale: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.

Question 5 of 5

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?

Correct Answer: D

Rationale: A fever of 100.9 F post-arteriovenous graft suggests possible infection, requiring immediate assessment. Cramping and minor bleeding are expected post-polypectomy, urinary hesitancy is common post-hernia repair, and straining is less urgent.

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