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Question 1 of 5

The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.

Question 2 of 5

The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?

Correct Answer: D

Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.

Question 3 of 5

The nurse is screening clients for those at risk for developing oral candidiasis. The nurse should recognize the client at highest risk for developing oral candidiasis is a client who

Correct Answer: C

Rationale: An HIV-positive client on long-term antibiotics is at highest risk for oral candidiasis due to immunosuppression and microbial imbalance. Albuterol use , sugary drinks , and low albumin are less significant risk factors.

Question 4 of 5

A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?

Correct Answer: A

Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.

Question 5 of 5

The client has contact dermatitis from poison ivy. Which statement, if made by the client, indicates that he understands how to care for his condition?

Correct Answer: C

Rationale: A cool wet cloth soothes itching and inflammation in contact dermatitis. Hot baths, strong soaps, or wool exacerbate irritation.

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