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Question 1 of 5

The nurse is caring for an adult who had a transsphenoidal hypophysectomy earlier today. The client is now on the surgical unit after an uneventful stay in the postanesthesia care unit. How should the nurse position the client?

Correct Answer: C

Rationale: Semi-reclining reduces intracranial pressure and prevents cerebrospinal fluid leakage post-transsphenoidal hypophysectomy. Supine increases leakage risk, and upright or side-lying are less optimal.

Question 2 of 5

An adult is receiving total parenteral nutrition (TPN). Which assessment is essential for the nurse to make?

Correct Answer: D

Rationale: Daily weights monitor fluid balance and nutritional status, critical for TPN to prevent overload or malnutrition. TPN is intravenous, not gastric, and bowel movements/sounds are less relevant.

Question 3 of 5

Which of the following nursing assessments for an infant is most valuable in identifying serious visual defects?

Correct Answer: A

Rationale: Red reflex test. A uniform red reflex rules out most serious defects of the cornea, lens, and vitreous chamber.

Question 4 of 5

The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this the nurse should:

Correct Answer: B

Rationale: Positive reinforcement of expressed feelings encourages the client to continue sharing emotions, reducing reliance on denial. Direct confrontation or instruction may increase resistance. Psychosocial Integrity

Question 5 of 5

A nurse's aide who had a tuberculosis test planted two days ago has a reddened area 15-mm in diameter. The aide asks the nurse what this means. The nurse understands that the test result is:

Correct Answer: D

Rationale: Redness alone without induration is not significant; a positive TB test requires a raised area ≥10 mm, indicating this is negative.

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