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Questions 148

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Extract:


Question 1 of 5

The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?

Correct Answer: D

Rationale: implementation, fixed and dilated pupil represents a neurological emergency

Question 2 of 5

The newly graduated nurse is caring for an elderly client on the medical-surgical floor. The nurse recalls learning about client advocacy. Which actions by the nurse indicate an understanding of client advocacy? Select all that apply.

Correct Answer: C,D,E

Rationale: Ensuring understanding of treatment options, obtaining an interpreter, and discussing advance directives promote client autonomy and rights. Other actions assume incapacity or impose personal views.

Question 3 of 5

A home health nurse visits a 7-year-old boy on neutropenic precautions. His mother cares for him during the day. Which of the following statements by the mother indicates a need for further teaching?

Correct Answer: C

Rationale: Live vaccines (e.g., nasal flu vaccine) require a 3-week wait, but the standard flu shot is inactivated, posing no risk. The other statements are correct for neutropenic precautions.

Question 4 of 5

The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

Correct Answer: C

Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.

Question 5 of 5

The nurse is caring for a client scheduled for a surgical repair of an abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

Correct Answer: C

Rationale: Identifying peripheral pulses is critical to establish a baseline for vascular status, as an abdominal aortic aneurysm repair can affect blood flow to the extremities, and postoperative complications may include vascular occlusion.

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