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Questions 158

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Extract:


Question 1 of 5

When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

Correct Answer: C

Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.

Question 2 of 5

The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?

Correct Answer: C

Rationale: Turning the client to one side prevents aspiration, a priority in a nauseated CVA client with potential swallowing deficits. Administering an antiemetic (
A) or notifying the physician (
D) is secondary, and ice (
B) is ineffective.

Question 3 of 5

An obstructing stone in the renal pelvis or upper ureter causes:

Correct Answer: C

Rationale: Radiating pain in the urethra in both sexes, extending into the labia in females and into the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter. Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter within the bladder wall. An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor. Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the renal pelvis or upper ureter causes severe flank and abdominal pain.

Question 4 of 5

The nurse is caring for a client after a burn. Which assessment finding best indicates that the client's respiratory efforts are currently adequate?

Correct Answer: C

Rationale: An O2 saturation of 97% directly indicates adequate oxygenation from respiratory efforts. Talking (
A), alertness (
B), and chest movement (
D) are indirect and less specific.

Question 5 of 5

A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

Correct Answer: D

Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.

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