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Questions 149

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Extract:


Question 1 of 5

The nurse is performing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?

Correct Answer: D

Rationale: Polycythemia vera increases blood viscosity, raising thrombosis risk. Teaching clients to recognize thrombosis symptoms (e.g., swelling, pain) is critical for early intervention.

Question 2 of 5

A client is receiving hospice and palliative care, including analgesia and other comfort measures. Which of the following indicates the client is undergoing life review? Select all that apply.

Correct Answer: A,C

Rationale: Looking at photos (
A) and reminiscing about parenting (
C) indicate life review, reflecting on past experiences. Other statements (B, D, E) relate to pain or end-of-life wishes.

Question 3 of 5

The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:

Correct Answer: B

Rationale: Absent variability on the fetal monitor indicates fetal distress, suggesting compromised oxygenation.

Question 4 of 5

The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?

Correct Answer: C

Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.

Question 5 of 5

The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?

Correct Answer: C

Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space

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