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Questions 163

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Question 1 of 5

The nurse begins to assist with ambulation of a 9-year-old client who is 1 day postoperative appendectomy when the child cries out, 'It hurts too much. I can't do it.' Which action should the nurse complete first?

Correct Answer: B

Rationale: Assessing pain level using a numeric scale is the first step to quantify the child's pain and determine the need for analgesics or other interventions. Administering analgesics without assessment is premature, delaying ambulation avoids addressing pain, and encouraging walking ignores the child's distress.

Question 2 of 5

The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Appropriate scopolamine instructions include safe disposal , removing old patches , correct placement , and hand washing . Applying the patch only when moving is incorrect, as it should be applied hours before travel.

Question 3 of 5

Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

Correct Answer: A,B,D,E

Rationale: UAP can ambulate stable clients , check pulse oximetry , provide oral hygiene , and reposition clients . Instructing on incentive spirometry requires nursing judgment and is not delegable.

Question 4 of 5

A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies

Correct Answer: C

Rationale: boost the immune system. The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body's own defenses.

Question 5 of 5

In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?

Correct Answer: C

Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.

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