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Question 1 of 5

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:

Correct Answer: B

Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.

Question 2 of 5

The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?

Correct Answer: A

Rationale: Hyperventilation reduces PaCO2, causing cerebral vasoconstriction, which decreases cerebral blood flow and edema. The other options address pressure or fluid but not vasoconstriction.

Question 3 of 5

The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:

Correct Answer: A

Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.

Question 4 of 5

A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?

Correct Answer: B

Rationale: Renal biopsies may cause discomfort during needle insertion, and informing the client prepares them for the procedure.

Question 5 of 5

The charge nurse in a cardiac ICU is precepting a student nurse. Which action by the student nurse requires immediate intervention by the charge nurse?

Correct Answer: B

Rationale: Lifting the urinary catheter bag above the bladder risks backflow of urine, increasing infection risk, and requires immediate intervention.

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A nursing instructor demonstrates to several students how to wrap an amputated limb in a bandage using a figure eight technique. Which of the following correctly states the benefits of this technique? Select all that apply.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
The nurse should carefully monitor the client for which common dysrhythmia that can occur during suctioning?
A client has been diagnosed with renal insufficiency, which has led to pronounced fluid volume excess. The nurse would expect which of the following signs and symptoms? Select all that apply.

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