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Questions 164

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Question 1 of 5

The nurse talking with a client with polycythemia vera. Which of the following statements by the client would require follow-up?

Correct Answer: D

Rationale: Iron supplements can worsen polycythemia vera by increasing red blood cell production. Hydration, aspirin, and phlebotomy are appropriate management strategies.

Question 2 of 5

The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?

Correct Answer: B

Rationale: Imitation of sounds. Eight-month-olds typically imitate sounds like 'da-da' as part of language development.

Question 3 of 5

What should the nurse do when ambulating a client who has a portable wound drainage system?

Correct Answer: B

Rationale: Fastening the drainage device below the wound promotes gravity-dependent drainage, preventing reflux and infection during ambulation.

Question 4 of 5

Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?

Correct Answer: B

Rationale: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement. When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.

Question 5 of 5

The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?

Correct Answer: D

Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.

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