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Questions 149

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Question 1 of 5

The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300 mL. The nurse should give priority to:

Correct Answer: D

Rationale: A chest tube output of 300 mL per hour is excessive and may indicate hemorrhage, requiring immediate physician notification.

Question 2 of 5

The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?

Correct Answer: C

Rationale: Alendronate should be taken with water only to ensure proper absorption and minimize esophageal irritation.

Question 3 of 5

The clinic record for a client reads: gravida 3, para 2. The admitting nurse is most correct to confirm which prenatal history?

Correct Answer: B

Rationale: Gravida 3, para 2 indicates three pregnancies and two births after 20 weeks’ gestation, regardless of outcome (live or stillbirth).

Question 4 of 5

A client delivered a 9-pound infant 2 hours ago. The client has an IV of D5W with oxytocin. The nurse determines that the medication is achieving the desired effect when she observes:

Correct Answer: D

Rationale: Oxytocin promotes uterine contractions, resulting in a firm fundus, which prevents postpartum hemorrhage and is the desired effect.

Question 5 of 5

The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

Correct Answer: B

Rationale: Sternal bruises suggest potential chest trauma, requiring priority.

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