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Questions 163

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Question 1 of 5

The nursing care plan for a client with decreased adrenal function should include

Correct Answer: C

Rationale: Limiting visitors. Limiting visitors reduces physical and emotional exertion, preventing an Addisonian crisis.

Question 2 of 5

An adult who had a laryngectomy is ready for discharge. What question is it essential for the nurse to ask the client before discharge?

Correct Answer: B

Rationale: Smoke detectors are critical post-laryngectomy, as impaired speech and potential airway issues increase fire safety risks, making this a priority discharge question.

Question 3 of 5

In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?

Correct Answer: C

Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.

Question 4 of 5

The physician has recommended that the client increase the amount of dietary iron. The nurse knows that the client understands the recommendation when the client selects which foods?

Correct Answer: C

Rationale: Roast beef is high in iron, suitable for increasing dietary iron. Other options lack significant iron sources.

Question 5 of 5

The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to

Correct Answer: A

Rationale: Avoid caffeine. Caffeine can trigger vasoconstriction, exacerbating Raynaud's phenomenon symptoms, making it a priority after smoking cessation.

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