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Question 1 of 5

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?

Correct Answer: D

Rationale: A fever of 100.9 F post-arteriovenous graft suggests possible infection, requiring immediate assessment. Cramping and minor bleeding are expected post-polypectomy, urinary hesitancy is common post-hernia repair, and straining is less urgent.

Question 2 of 5

The nurse is reinforcing information to a diabetic client with a new prescription for metoclopramide. Which of the following side effects must the nurse remind the client to report immediately to the health care provider? Select all that apply.

Correct Answer: A,D,E

Rationale: Metoclopramide can cause tardive dyskinesia, with symptoms like excess blinking , lip smacking , and cheek puffing , requiring immediate reporting. Dry mouth and headache are common and less urgent.

Question 3 of 5

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.

Correct Answer: B,C,D,E

Rationale: For shoulder dystocia: document timing for accuracy, flex legs for McRoberts maneuver, request help for additional support, and apply suprapubic pressure to dislodge the shoulder. Fundal massage is for postpartum hemorrhage.

Question 4 of 5

The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding?

Correct Answer: C,D

Rationale: Stopping coffee 24 hours before prevents interference with the stress test, and taking insulin as usual maintains glycemic control. Smoking and eating a large meal can alter test results.

Question 5 of 5

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

Correct Answer: C

Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.

Similar Questions

The nurse notes all of the following. Which should be attended to first?
A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client?
A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32 kg/m². Which teachings should the nurse reinforce as part of proper preconception health care for this client? Select all that apply.
In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
The nurse is reinforcing instructions related to antibiotic eye drop administration to the parent of a 5-year-old with bacterial conjunctivitis. Which instruction is most important?

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