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Questions 163

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Question 1 of 5

The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?

Correct Answer: C

Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.

Question 2 of 5

Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

Correct Answer: C

Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, requiring immediate intervention. Crying, wakefulness, and yawning are normal behaviors, so A, B, and D are incorrect.

Question 3 of 5

The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?

Correct Answer: B

Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.

Question 4 of 5

In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?

Correct Answer: C

Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.

Question 5 of 5

The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?

Correct Answer: D

Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.

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