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Questions 149

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Question 1 of 5

The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?

Correct Answer: C

Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.

Question 2 of 5

Four days after delivery, a client develops complications of postpartal hemorrhage. The most common cause of late postpartal hemorrhage is:

Correct Answer: B

Rationale: Retained placental fragments are the most common cause of late postpartum hemorrhage, as they prevent proper uterine contraction and hemostasis.

Question 3 of 5

The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?

Correct Answer: A

Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.

Question 4 of 5

The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?

Correct Answer: C

Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space

Question 5 of 5

A client admitted with gastroenteritis and a potassium level of 2.9 mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client's potassium results?

Correct Answer: A

Rationale: Hypokalemia (2.9 mEq/dL) can cause a depressed ST segment, flattened T waves, and prominent U waves on ECG due to altered cardiac repolarization.

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