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Questions 158

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Question 1 of 5

An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

Correct Answer: B

Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.

Question 2 of 5

A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:

Correct Answer: A

Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.

Question 3 of 5

A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse's assessment of this response is:

Correct Answer: C

Rationale: Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. There are no data to support this. This statement by the mother still leaves room for exploration. Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. It is not abnormal. If it were, another month would also be too long to wait.

Question 4 of 5

A client who had major abdominal surgery is having delayed healing of the wound. Which laboratory test result would most closely correlate with this problem?

Correct Answer: A

Rationale: Decreased albumin indicates protein deficiency, impairing tissue repair and delaying wound healing. Decreased creatinine (
B) reflects renal function, increased calcium (
C) affects bones, and increased sodium (
D) affects fluid balance, not healing directly.

Question 5 of 5

The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?

Correct Answer: B

Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (
A) is secondary, an ACE bandage (
C) may contaminate the wound, and prone positioning (
D) is inappropriate.

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