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Question 1 of 5

The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:

Correct Answer: B

Rationale: After rupture of membranes, assessing fetal heart tones is critical to detect distress, such as cord prolapse. Monitoring, anesthesia, and catheterization are secondary priorities.

Question 2 of 5

The nurse is teaching a client with a history of osteoporosis about fall prevention. The nurse should tell the client to:

Correct Answer: A

Rationale: Removing clutter prevents falls in osteoporosis, reducing fracture risk.

Question 3 of 5

The nurse is teaching a client with hypertension about dietary modifications. Which food choice indicates a need for further teaching?

Correct Answer: C

Rationale: Canned soup is high in sodium, which exacerbates hypertension, indicating a need for further teaching. Apple (
A), chicken (
B), and broccoli (
D) are low-sodium and appropriate.

Question 4 of 5

A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:

Correct Answer: C

Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.

Question 5 of 5

A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?

Correct Answer: C

Rationale: Paresthesia of hands and feet indicates B12 deficiency due to noncompliance with injections, as B12 is needed for nerve function. Hyperactivity (
A), weight gain (
B), and diarrhea (
D) are not specific to B12 deficiency.

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