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Questions 148

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Extract:


Question 1 of 5

The nurse should visit which of the following clients first?

Correct Answer: C

Rationale: Chest pain in a client with a history of angina suggests possible cardiac ischemia, requiring immediate assessment.

Question 2 of 5

The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs $73.5 \mathrm{gm}$. The diaper's dry weight was $62 \mathrm{gm}$. The newborn's urine output is:

Correct Answer: B

Rationale: Urine output is calculated by subtracting dry diaper weight from wet diaper weight: 73.5 gm - 62 gm = 11.5 ml (1 gm = 1 ml for urine).

Question 3 of 5

The nurse is caring for a client who is postoperative day 3 following a bowel resection. The client reports sudden, severe abdominal pain and distention. Which of the following actions should the nurse take FIRST?

Correct Answer: B

Rationale: sudden, severe abdominal pain and distention may indicate a complication such as an anastomotic leak, requiring immediate physician notification

Question 4 of 5

A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?

Correct Answer: C

Rationale: An unusual swelling pattern after removing an elastic wrap suggests incorrect wrap technique (
C), which can cause uneven pressure. Infection (
A), impaired circulation (
B), or bleeding (
D) would present differently.

Question 5 of 5

The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should:

Correct Answer: D

Rationale: Increased bile-tinged drainage may indicate a complication, such as a leak, requiring physician notification.

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