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Questions 163

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Question 1 of 5

The nurse is collecting data from a client who delivered a full-term newborn vaginally 12 hours ago after prolonged labor. Which of the following findings would be essential to follow up?

Correct Answer: A

Rationale: Foul-smelling lochia suggests possible endometritis or infection, requiring immediate follow-up. External hemorrhoids and mild temperature elevation are common postpartum findings, and discomfort during fundal massage is expected unless accompanied by other concerning signs.

Question 2 of 5

The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?

Correct Answer: C

Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.

Question 3 of 5

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, 'I can't breathe.' The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?

Correct Answer: C

Rationale: For a COPD client with anxiety-driven dyspnea, stable vitals, and clear lungs, coaching controlled breathing helps reduce anxiety and improve breathing patterns. Albuterol is for bronchospasm, trigger identification is secondary, and monitoring is insufficient alone.

Question 4 of 5

The nurse is caring for a client who is in the first stage of labor and is reporting intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: For back pain in labor with a right occiput posterior position, applying counterpressure to the sacrum relieves discomfort. Supine position worsens pain, bed rest limits mobility, and epidural is not the first intervention.

Question 5 of 5

The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?

Correct Answer: B

Rationale: Assessing breath sounds is the first step to evaluate the extent of fluid overload and guide interventions in heart failure. Oxygen , monitoring , and IV insertion follow based on findings.

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