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Questions 158

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Question 1 of 5

The nurse is teaching a client with a history of psoriasis about skin care. The nurse should tell the client to:

Correct Answer: A

Rationale: Moisturizing the skin helps reduce dryness and scaling in psoriasis, improving skin barrier function and comfort.

Question 2 of 5

The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:

Correct Answer: A

Rationale: A full bladder would cause discomfort and possible urinary incontinence during the exam. The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. Arms extended over the head would cause the abdomen to be tighter and less easily palpable. Forcing fluids would encourage a full bladder, which is not desired for the exam.

Question 3 of 5

A client is admitted with a blood glucose level of 740 mg/dl. Which actions should the nurse take at this time?

Question Image

Correct Answer: C, E, F

Rationale: Hyperglycemia (740 mg/dl) requires physician notification (
C), sliding scale regular insulin (E), and consciousness assessment (F) for potential diabetic ketoacidosis. Peripheral neuropathy (
A) is chronic, not acute. Dextrose (
B) worsens hyperglycemia. NPH insulin (
D) is long-acting, unsuitable for acute management.

Question 4 of 5

A vaginal exam reveals that the cervix is 4cm dilated,with intact membranes and a fetal heart tone rate of 160-170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:

Correct Answer: B

Rationale: External fetal monitoring is appropriate when membranes are intact as internal monitoring requires ruptured membranes. The cervix is not closed fetal heart tones are normal and contraction intensity is irrelevant to external monitoring.

Question 5 of 5

The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse's action would be:

Correct Answer: D

Rationale: (A, B,
C) The last request from the husband overrides the decision not to initiate resuscitation efforts. The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.

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