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Questions 164

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Extract:


Question 1 of 5

The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?

Correct Answer: A

Rationale: Assisting with mobility, such as to the bathroom, is within the nursing assistant's scope. Wound assessment, tube discontinuation, and treating hypoglycemia require nursing judgment and are outside their scope.

Question 2 of 5

An adult who has osteoarthritis tells the clinic nurse that her joints have been more painful lately and her head aches and her ears are 'making funny buzzing sounds.' What question should the nurse ask the client?

Correct Answer: D

Rationale: New symptoms with increased joint pain suggest possible medication side effects (e.g., NSAIDs causing tinnitus), making medication history critical.

Question 3 of 5

Written instructions to pregnant women include instructions to perform Kegel exercises. One of the women asks the nurse why these exercises are important. The nurse should reply that the purpose of these exercises is to:

Correct Answer: B

Rationale: Kegel exercises strengthen pelvic floor muscles, supporting bladder control and aiding postpartum recovery, directly addressing their purpose.

Question 4 of 5

Which of the following instructions should be given to a client regarding testicular self-exam?

Correct Answer: B

Rationale: Testicular self-examination (TSE) is recommended monthly, not bimonthly or yearly, and is best performed during or after a warm shower or bath when the scrotum is relaxed, making it easier to detect abnormalities. Transillumination is a medical procedure, not part of TSE.

Question 5 of 5

A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?

Correct Answer: B

Rationale: Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.

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