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Questions 160

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Question 1 of 5

During the first stage of a client's labor, the nurse finds that the fetal heart rate decreases during a contraction and returns to normal at the end of the contraction. Which action is the most appropriate in response to the assessment finding?

Correct Answer: A

Rationale: A temporary fetal heart rate decrease during contractions (early deceleration) is normal, indicating head compression, and requires no action.

Question 2 of 5

The nurse is caring for a client with a history of anaphylaxis. Which medication should be readily available?

Correct Answer: A

Rationale: Epinephrine is the first-line treatment for anaphylaxis to reverse airway constriction and shock.

Question 3 of 5

A client with a history of bipolar disorder is prescribed lithium. Which laboratory value should the nurse monitor?

Correct Answer: B

Rationale: Serum lithium levels must be monitored to ensure therapeutic range (0.6–1.2 mEq/L) and prevent toxicity.

Question 4 of 5

Laboratory data for an adult client diagnosed with Pneumocystis carinii pneumonia indicate immunosuppression. Which is the most important in determining the client's susceptibility to this infection?

Correct Answer: D

Rationale: Pneumocystis carinii pneumonia is associated with immunosuppression, often linked to HIV, which is commonly transmitted through sexual practices.

Question 5 of 5

What are the priorities when planning the care of a 75-year-old hospitalized client who develops pneumonia? Select all that apply.

Correct Answer: B,E,F

Rationale: Maintaining oxygenation addresses hypoxia, a critical issue in pneumonia. Administering antibiotics promptly and obtaining blood cultures ensure timely treatment and accurate diagnosis.

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