Extract:

Question 1 of 5

The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?

Correct Answer: A

Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.

Question 2 of 5

The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?

A. First maneuver. B. Second maneuver. C. Third maneuver. D. Fourth maneuver.

Correct Answer: C

Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence

Question 3 of 5

The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?

A. Vital signs B. Motor function C. Sensory function D. Level of consciousness

Correct Answer: D

Rationale: The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.

Question 4 of 5

Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:

A. 1 to 2 mL/kg/hour. B. 3 to 5 mL/kg/hour. C. 6 to 8 mL/kg/hour. D. 10 to 12 mL/kg/hour.

Correct Answer: A

Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.

Question 5 of 5

A client has been prescribed metoclopramide on a long-term basis. A home care nurse calls the primary health care provider immediately if which side effect is noted in this client?

A. Excitability B. Anxiety or irritability C. Uncontrolled rhythmic movements of the face or limbs D. Dry mouth not minimized by the use of sugar-free hard candy

Correct Answer: C

Rationale: Metoclopramide is a 'prokinetic' drug used to treat heartburn. If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should withhold the medication and call the primary health care provider. These side effects may be irreversible. Excitability is not a side effect of this medication. Anxiety, irritability, and dry mouth are milder side effects that are not harmful to the client.