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Questions 210

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Question 1 of 5

The client screams at the nurse, 'You are all incompetent here! I have been waiting for 2 hours!' How should the nurse respond initially?

Correct Answer: C

Rationale: Acknowledging the client's frustration and offering assistance de-escalates the situation and focuses on solutions. Threatening security escalates tension, and the other options dismiss the client's feelings or fail to address the issue.

Question 2 of 5

A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is

Correct Answer: A

Rationale: Central nervous system damage. The most serious consequences of chronic lead poisoning occur in the central nervous system, leading to intellectual deficits or even death.

Question 3 of 5

The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

Correct Answer: C

Rationale: Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.

Question 4 of 5

A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is

Correct Answer: C

Rationale: Establishing an open airway is always the primary objective in a cardiopulmonary arrest.

Question 5 of 5

The nurse is caring for a client immediately after a vaginal birth. The nurse notes that the client’s uterus is midline and boggy. Which of the following actions should the nurse take first?

Correct Answer: A

Rationale: A boggy uterus indicates uterine atony, a major cause of postpartum hemorrhage. Fundal massage is the first action to stimulate contractions and expel clots. Adjusting oxytocin, checking vitals, or looking for blood are secondary after initiating massage.

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