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Question 1 of 5

The nurse is caring for a newborn who has a large myelomeningocele. It would be a priority for the nurse to

Correct Answer: B

Rationale: A myelomeningocele requires a sterile, moist dressing (
B) to prevent infection and drying. Checking anus tone (
A), measuring head circumference (
C), and supine positioning (
D) are secondary or contraindicated.

Question 2 of 5

A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?

Correct Answer: D

Rationale: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.

Question 3 of 5

An alert adult is being admitted for elective surgery. Which comment made by the client indicates a need for more instruction regarding advance directives?

Correct Answer: B

Rationale: Advance directives allow clients to specify care preferences, not relinquish decision-making entirely. This comment suggests a misunderstanding that requires further education.

Question 4 of 5

The nurse receives the handoff of care report on four clients. Which client should the nurse see first?

Correct Answer: D

Rationale: Restlessness in a pneumonia client with low SpO2 (
D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (
A) is urgent but stable. Pleural effusion (
B) and fever (
C) are less critical.

Question 5 of 5

A 43-year-old woman with lupus erythematosus expresses frustration about the unpredictable course of her illness and the change in her physical appearance. Which nursing intervention would be most appropriate?

Correct Answer: A

Rationale: Exploring lupus' impact on her life validates her frustrations, addressing emotional and social effects therapeutically.

Similar Questions

The school nurse observes a 7-year-old client with attention deficit hyperactivity disorder begin to throw books and attempt to hit the classmates. Which of the following actions would be a priority for the nurse to take?
A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse?
A woman is pregnant for the first time and is Rh negative. Her husband is Rh positive. She tells the nurse that he is very worried about her baby. Which information should the nurse plan to include when talking with this woman?
The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?
The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?

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