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Questions 148

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Question 1 of 5

The nurse is caring for a client who is postoperative day 3 following a bowel resection. The client reports sudden, severe abdominal pain and distention. Which of the following actions should the nurse take FIRST?

Correct Answer: B

Rationale: sudden, severe abdominal pain and distention may indicate a complication such as an anastomotic leak, requiring immediate physician notification

Question 2 of 5

A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:

Correct Answer: D

Rationale: Absence seizures cause brief lapses in consciousness, often appearing as staring spells, without motor symptoms.

Question 3 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 4 of 5

The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?

Correct Answer: D

Rationale: implementation, fixed and dilated pupil represents a neurological emergency

Question 5 of 5

A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?

Correct Answer: B

Rationale: The supine position provides optimal access to the sternum for bone marrow aspiration and ensures client safety and comfort.

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