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Questions 148

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Question 1 of 5

The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

Correct Answer: C

Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.

Question 2 of 5

The nurse is on a memory care unit. A client insists on leaving to go home. Which of the following should the nurse do?

Correct Answer: B

Rationale: Redirecting the client to a social activity can help distract from the desire to leave and promote engagement, which is appropriate for a client with memory issues.

Question 3 of 5

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Correct Answer: B

Rationale: The vital signs indicate shock, so contacting the physician for immediate intervention is the priority.

Question 4 of 5

A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?

Correct Answer: D

Rationale: Pain (
D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (
A), vital signs (
B), and oxygen saturation (
C) are secondary.

Question 5 of 5

A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means

Correct Answer: A

Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.

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