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Questions 149

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Question 1 of 5

The clinic record for a client reads: gravida 3, para 2. The admitting nurse is most correct to confirm which prenatal history?

Correct Answer: B

Rationale: Gravida 3, para 2 indicates three pregnancies and two births after 20 weeks’ gestation, regardless of outcome (live or stillbirth).

Question 2 of 5

A client with hyperkalemia is admitted to the telemetry unit. Which of the following would require notification of the health care provider? Select all that apply.

Correct Answer: A, B

Rationale: Spiked T waves and bradycardia (heart rate 53) are signs of severe hyperkalemia, requiring immediate provider notification. Normal heart rate, food refusal, and adequate urinary output (30 cc/hr) are not urgent.

Question 3 of 5

The nurse is discharging a client with a prescription of eyedrops. Which observation by the nurse would indicate a need for further client teaching?

Correct Answer: B

Rationale: Administering a second eyedrop immediately washes out the first. A 5-minute wait is needed, indicating a need for further teaching.

Question 4 of 5

A client seen in the doctor's office for complaints of nausea and vomiting is sent home with directions to follow a clear-liquid diet for the next 24-48 hours. Which of the following is not permitted on a clear-liquid diet?

Correct Answer: C

Rationale: Ice cream is not a clear liquid, as it is opaque and contains dairy.

Question 5 of 5

A teenage girl is brought to the outpatient psychiatric clinic for treatment of anxiety and depression. How should the nurse best evaluate the client's risk for suicide?

Correct Answer: A

Rationale: Directly asking about suicidal thoughts or plans is the most effective way to assess suicide risk, as it encourages open communication and identifies intent.

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