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Question 1 of 5

The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:

Correct Answer: A

Rationale: A full bladder would cause discomfort and possible urinary incontinence during the exam. The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. Arms extended over the head would cause the abdomen to be tighter and less easily palpable. Forcing fluids would encourage a full bladder, which is not desired for the exam.

Question 2 of 5

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Correct Answer: B

Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Question 3 of 5

A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:

Correct Answer: B

Rationale: This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.

Question 4 of 5

A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:

Correct Answer: B

Rationale: A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage.

Question 5 of 5

The nurse is caring for a client diagnosed with metastatic cancer of the bone. The client is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?

Correct Answer: B

Rationale: Hypercalcemia (calcium 13 mg/dL) is a common complication of bone metastases, causing confusion and hypertension. Hyperkalemia (
A), low phosphorus (
C), and normal sodium (
D) are less likely causes.

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