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Question 1 of 5

The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:

Correct Answer: C

Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.

Question 2 of 5

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Correct Answer: A

Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.

Question 3 of 5

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

Correct Answer: B

Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.

Question 4 of 5

A client is being treated with internal radiation (brachytherapy). The nurse explains to the client that

Correct Answer: C

Rationale: Brachytherapy requires distance precautions; visitors must stay 6 feet away to minimize radiation exposure. Gowns/masks are not needed, visitors are allowed, and gifts do not become radioactive.

Question 5 of 5

During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse's first action should be to:

Correct Answer: B

Rationale: A narcotic discrepancy requires reporting to the supervisor for investigation.

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The nurse plans on administering a medication using the Z-track intramuscular technique. The nurse knows the following steps are required during the procedure. Select all that apply.
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for:
A client develops mastitis in the postpartum period. Which of the following instructions does the nurse anticipate when notifying the physician? Select all that apply.

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