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Questions 163

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Question 1 of 5

The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?

Correct Answer: A

Rationale: Estrogen increases the hypercoagulability of the blood and increases the risk for development of thrombophlebitis.

Question 2 of 5

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?

Correct Answer: C

Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.

Question 3 of 5

The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.

Correct Answer: A,D,E

Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.

Question 4 of 5

The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed

Correct Answer: C

Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B,
D) follow correct infection control protocols.

Question 5 of 5

The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

Correct Answer: A

Rationale: High in carbohydrates and proteins. This diet supports energy needs and compensates for malabsorption in cystic fibrosis.

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