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Questions 164

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Question 1 of 5

The family of a frail elderly man who is bedridden asks the nurse what they can do to prevent bedsores. Which response by the nurse is best?

Correct Answer: B

Rationale: Turning every two hours relieves pressure on bony prominences, preventing pressure ulcers. Getting out of bed may be infeasible, and rubbing or sheet changes are less effective.

Question 2 of 5

The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: A

Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.

Question 3 of 5

The nurse is collecting data from assigned clients. It would require follow-up if a

Correct Answer: C

Rationale: A 6-month-old weighing only 12 lb (5400 g) from a birth weight of 7 lb 3 oz (3300 g) indicates failure to thrive, requiring follow-up. Other findings (fontanels, 12-month-old weight) are within normal ranges.

Question 4 of 5

A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?

Correct Answer: C

Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.

Question 5 of 5

The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?

Correct Answer: C

Rationale: Hemophilia A is characterized by an absence or deficiency of Factor VIII.

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