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Extract:


Question 1 of 5

The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse:

Correct Answer: B,D,C,A

Rationale: Redness suggests an allergic reaction or 'red man syndrome' from rapid vancomycin infusion. The nurse should: stop the infusion to prevent further reaction, take vital signs to assess severity, administer Benadryl if ordered, and call the doctor for further orders.

Extract:

The importance of monitoring blood sugar, activity level, and insulin doses is to


Question 2 of 5

adjust the activity level based on the blood sugar level.

Correct Answer: B

Rationale: If a patient injects too much insulin, exercises too much in relation to carbohydrate consumed, or does not eat enough or at the appropriate times, the blood glucose level can fall low enough to cause hypoglycemia. Adjusting diet and insulin doses based on activity level helps maintain balance.

Extract:


Question 3 of 5

Which of the following clients is at greatest risk for postpartal hemorrhage?

Correct Answer: D

Rationale: A gravida 4 para 3 with a Caesarean section is at higher risk for postpartal hemorrhage due to multiparity and surgical delivery, which can lead to uterine atony and increased bleeding risk.

Extract:

For proper foot care, the nurse should provide a patient with non-insulin dependent mellitus with instructions to:


Question 4 of 5

For proper foot care, the nurse should provide a patient with non-insulin dependent mellitus with instructions to:

Correct Answer: B

Rationale: Wearing shoes and natural fiber socks protects diabetic feet and promotes circulation.

Extract:


Question 5 of 5

A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:

Correct Answer: B

Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care

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