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Questions 158

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Question 1 of 5

The nurse is caring for a client with a diagnosis of gestational hypertension. Which intervention is most appropriate?

Correct Answer: D

Rationale: Gestational hypertension requires blood pressure monitoring to assess severity antihypertensives for severe hypertension and fetal heart tone monitoring to ensure fetal well-being. All interventions are appropriate.

Question 2 of 5

The nurse is teaching the client with hepatitis B regarding transmission. The nurse should instruct the client to do which of the following?

Question Image

Correct Answer: B, E

Rationale: Hepatitis B is transmitted via blood and bodily fluids. Avoiding sharing toothbrushes (
B) prevents transmission through saliva or blood. Informing the dentist (E) ensures precautions during procedures. Eating fresh produce (
A), cleaning the commode (
C), and boiling water (
D) are unrelated to hepatitis B transmission.

Question 3 of 5

A client requires log rolling after back surgery. Correctly provide the sequence of steps the nurse should follow when performing the procedure.

Order the Items

Source Container

Obtain assistance; three nurses are preferable.
Maintain client's position in alignment with pillows.
Position two nurses on the side the client will be turned to and the third nurse on the opposite side of the bed.
Designate the person at the head of the bed to be in charge of coordinating the move.
Place a pillow between the client's knees.
Move the client in one coordinated movement when the nurse at the head of the bed signals to move the client.
Instruct the client to place the arms across the chest.

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

Rationale: Log rolling sequence: Obtain assistance (
A), position nurses (
C), designate leader (
D), instruct arm placement (G), place pillow (E), align with pillows (
B), move coordinately (F).

Question 4 of 5

A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:

Correct Answer: A

Rationale: Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. These side effects do not necessarily resolve in time; however, the client may adapt.

Question 5 of 5

Priapism may be a sign of:

Correct Answer: A

Rationale: Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. It is not associated with death, urinary incontinence, or reproductive dysfunction as a primary issue.

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