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Questions 160

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Question 1 of 5

The nurse is assessing a postmenopausal woman for evidence of heart disease- Which factor contributes to the client's increased risk for heart disease after menopause?

Correct Answer: A

Rationale: A. Estrogen has a positive and protective effect on the function of the heart and blood vessels. B. Menopause is not known to cause a specific food craving. C. Progesterone, which decreases with menopause, is more linked to weight gain. D. Continued exercise and activity in menopause positively affects a woman's health.

Question 2 of 5

During the first stage of a client's labor, the nurse finds that the fetal heart rate decreases during a contraction and returns to normal at the end of the contraction. Which action is the most appropriate in response to the assessment finding?

Correct Answer: A

Rationale: A temporary fetal heart rate decrease during contractions (early deceleration) is normal, indicating head compression, and requires no action.

Question 3 of 5

At the time of a retinal detachment, the client will most likely experience which effects? Select all that apply.

Correct Answer: A,F

Rationale: Retinal detachment causes flashes of light due to retinal traction and wavy vision (floaters or curtain-like vision) due to retinal separation. Severe pain or inability to see light is not typical.

Question 4 of 5

The nurse is assessing a client with suspected appendicitis. Which finding supports this diagnosis?

Correct Answer: B

Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis.

Question 5 of 5

A client diagnosed with a GI bleed has received an order for a blood transfusion. Place the nursing actions in the correct order for administering the blood transfusion.

Order the Items

Source Container

Verify the client's identity and blood product with another nurse.
Obtain the client's baseline vital signs.
Start the blood transfusion at a slow rate.
Monitor the client for transfusion reactions.
Prime the IV tubing with normal saline.

Correct Answer: B,E,A,C,D

Rationale: 1. Obtain baseline vital signs to assess for changes. 2. Prime IV tubing with normal saline to ensure compatibility. 3. Verify identity and blood product to prevent errors. 4. Start transfusion slowly to monitor for reactions. 5. Monitor for transfusion reactions throughout.

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