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Questions 149

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Extract:


Question 1 of 5

The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?

Correct Answer: B

Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.

Question 2 of 5

The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:

Correct Answer: B

Rationale: Loss of concentration is an early cognitive change in AIDS dementia complex.

Question 3 of 5

The newly licensed nurse has been asked to perform a procedure that he feels unqualified to perform. The nurse's best response at this time is to:

Correct Answer: B

Rationale: Refusing and explaining the lack of qualification ensures patient safety and adheres to ethical standards.

Question 4 of 5

As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?

Correct Answer: D

Rationale: Late decelerations indicate uteroplacental insufficiency, reducing fetal oxygenation during contractions.

Question 5 of 5

If a client is to have a nasogastric (NG) tube inserted for intermittent feedings, which of the following is an appropriate task to delegate to unlicensed assistive personnel?

Correct Answer: C

Rationale: Administering tube feedings (
C) can be delegated to unlicensed assistive personnel if trained, per facility policy. Inserting (
A), verifying (
B), and repositioning (
D) require nursing judgment.

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