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Questions 210

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Question 1 of 5

The nurse is contributing to the plan of care for a client with diabetes who reports breast tenderness, vaginal discharge, and urinary frequency. Which action is most important to include in the plan of care?

Correct Answer: C

Rationale: Determining the date of the client's last menstrual period is critical to assess for pregnancy or menopausal changes, which could explain the symptoms and impact diabetes management. Breast self-exams and vaginal discharge characteristics are less urgent, and blood sugar logs, while important, are not directly related to the reported symptoms.

Question 2 of 5

An adult is admitted to the hospital with several days of vomiting and diarrhea. Admitting data show RBC level of 4.2 million/mm³ and hematocrit of 54%. What is the best interpretation of these data?

Correct Answer: B

Rationale: Elevated hematocrit (normal: 36-46% for females, 41-53% for males) with normal RBC suggests hemoconcentration from dehydration due to fluid loss from vomiting and diarrhea.

Question 3 of 5

The licensed practical nurse is assisting the registered nurse with the triage of four clients. Which client should be cared for first?

Correct Answer: C

Rationale: Circumoral cyanosis and tachypnea indicate severe respiratory distress, requiring immediate care. Lacerations, burns, and nonreactive pupils are serious but less immediately life-threatening.

Question 4 of 5

Legal protection of confidentiality:

Correct Answer: D

Rationale: Confidentiality protects both written and verbal identifiable health information to maintain client privacy. Non-identifiable data may not require protection, and confidentiality is not limited to courts. Coordinated Care

Question 5 of 5

A 26-year-old woman with a history of heart disease is admitted in labor. She has been on bed rest for four months to prevent dyspnea. During labor, this client is likely to receive which of the following?

Correct Answer: D

Rationale: Epidural anesthesia minimizes cardiac stress and pain in labor for a patient with heart disease, safer than general anesthesia or Valsalva pushing.

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