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Questions 158

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Question 1 of 5

The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:

Correct Answer: C

Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.

Question 2 of 5

What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?

Correct Answer: A

Rationale: Human chorionic gonadotropin is the biochemical basis for pregnancy tests, produced by the placenta to maintain the corpus luteum.

Question 3 of 5

In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:

Correct Answer: B

Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.

Question 4 of 5

Which of the following signs might indicate a complication during the labor process with vertex presentation?

Correct Answer: D

Rationale: Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. Nausea and vomiting occur frequently during transition and are not a complication. Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.

Question 5 of 5

The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:

Correct Answer: A

Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.

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