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Questions 148

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Question 1 of 5

The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first?

Correct Answer: A

Rationale: Repositioning the client is the first step to improve fetal oxygenation if the fetal heart tone strip shows distress, as it is non-invasive and may resolve the issue.

Question 2 of 5

The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?

Correct Answer: C

Rationale: Clients with diverticulitis should avoid foods with seeds, such as tomatoes and cucumbers, as they can irritate diverticula. Bran, peaches, and dinner rolls are generally safe.

Question 3 of 5

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Correct Answer: B

Rationale: The vital signs indicate shock, so contacting the physician for immediate intervention is the priority.

Question 4 of 5

The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?

Correct Answer: D

Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.

Question 5 of 5

A client has suffered a severe electrical burn. Which medication would the nurse expect to have ordered for application to the burned area?

Correct Answer: D

Rationale: Silver sulfadiazine (Silvadene) is commonly used for electrical burns due to its broad-spectrum antimicrobial properties and soothing effect on burn wounds.

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