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Questions 148

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Question 1 of 5

The nurse is reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?

Correct Answer: A

Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.

Question 2 of 5

The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

Correct Answer: B

Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.

Question 3 of 5

The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.

Correct Answer: B, D, E

Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.

Question 4 of 5

The nurse is caring for a client with suspected endometrial cancer. Which symptom is associated with endometrial cancer?

Correct Answer: D

Rationale: Endometrial cancer often presents with abnormal uterine bleeding, which may manifest as watery or blood-tinged vaginal discharge. Frothy, thick white, or purulent discharges are more indicative of infections or other gynecologic conditions.

Question 5 of 5

The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?

Correct Answer: B

Rationale: A torque wrench is needed to adjust and maintain the tension of crutchfield tongs for cervical stabilization.

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