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Questions 164

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Question 1 of 5

The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to

Correct Answer: A

Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.

Question 2 of 5

The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel?

Correct Answer: A

Rationale: Checking blood glucose and reporting results is within UAP scope if trained. Teaching, monitoring for hypoglycemia, and updating care plans require nursing judgment and are outside UAP scope.

Question 3 of 5

An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?

Correct Answer: B

Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.

Question 4 of 5

The nurse is collecting data from assigned clients. It would require follow-up if a

Correct Answer: C

Rationale: A 6-month-old weighing only 12 lb (5400 g) from a birth weight of 7 lb 3 oz (3300 g) indicates failure to thrive, requiring follow-up. Other findings (fontanels, 12-month-old weight) are within normal ranges.

Question 5 of 5

The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?

Correct Answer: C

Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.

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