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Questions 158

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Question 1 of 5

The client is admitted with a diagnosis of molar pregnancy. Which nursing intervention is most appropriate?

Correct Answer: A

Rationale: Molar pregnancy involves abnormal trophoblastic tissue not a viable fetus and can cause significant vaginal bleeding. Monitoring for bleeding is the most appropriate intervention. Cesarean delivery tocolytics and fetal monitoring are not indicated.

Question 2 of 5

A client with a history of chronic migraines is admitted with complaints of nausea. The nurse should give priority to:

Correct Answer: A

Rationale: Antiemetics relieve nausea in migraines, improving comfort and preventing dehydration.

Question 3 of 5

A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:

Correct Answer: C

Rationale: Vital signs are a high priority when working with self-destructive clients.

Question 4 of 5

A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

Correct Answer: C

Rationale: The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.

Question 5 of 5

The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?

Question Image

Correct Answer: A, B, C

Rationale: West Nile virus is transmitted by mosquitoes (
A), blood transfusions (
B), and organ transplants (
C). Birds (
D) and horses (E) are hosts but not direct vectors to humans.

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