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Questions 149

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Question 1 of 5

The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:

Correct Answer: C

Rationale: In the emergent phase of burns, fluid volume deficit is the priority due to massive fluid loss from damaged skin, risking hypovolemic shock.

Question 2 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 3 of 5

The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

Correct Answer: C

Rationale: NPH insulin peaks 4-12 hours after administration, so a snack around 3 PM helps prevent hypoglycemia during peak action.

Question 4 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 5 of 5

A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.

Correct Answer: A, C, F

Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.

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