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Questions 227

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Extract:


Question 1 of 5

An appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus is:

Correct Answer: D

Rationale: Blood at the urethral meatus suggests trauma, contraindicating catheterization. A urologist consult is necessary for specialized evaluation and management. Physiological Adaptation

Question 2 of 5

The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. The nurse's priority action should be to

Correct Answer: A

Rationale: Terbutaline, a tocolytic, can cause maternal tachycardia. A pulse of 144 indicates significant tachycardia, a side effect requiring the medication to be withheld to prevent further cardiovascular strain. Decreasing the dose (
B) is not within nursing scope, administering (
C) ignores the risk, and waiting (
D) delays intervention.

Extract:

On the day of surgery, the nurse noted the following laboratory results.


Question 3 of 5

Which one should be reported to the surgeon immediately?

Correct Answer: B

Rationale: Elevated WBC is a sign of infection, which requires immediate reporting to the surgeon to assess the need to postpone surgery.

Extract:

When a patient return from the recovery room following a subtotal thyroidectomy, the nurse should immediately


Question 4 of 5

inspect the incision.

Correct Answer: D

Rationale: Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema also causes obstruction. Having a tracheostomy set ready is critical.

Extract:

Priority nursing diagnosis on the patient who was admitted with acute renal failure


Question 5 of 5

Priority nursing diagnosis on the patient who was admitted with acute renal failure would be:

Correct Answer: C

Rationale: Fatigue due to altered nutrition is a priority in acute renal failure as it reflects metabolic imbalances and nutritional deficits.

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