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Questions 158

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Question 1 of 5

On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:

Correct Answer: B

Rationale: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.

Question 2 of 5

The nurse is assessing a client with suspected tuberculosis. Which precaution should be implemented?

Correct Answer: B

Rationale: Tuberculosis is transmitted via airborne droplets, requiring airborne precautions (e.g., N95 mask, negative pressure room). Standard, droplet, and contact precautions are insufficient.

Question 3 of 5

The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?

Correct Answer: C

Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.

Question 4 of 5

A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

Correct Answer: B

Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.

Question 5 of 5

A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:

Correct Answer: C

Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases.

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