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Question 1 of 5

Which incidence should be documented on an unusual incident report?

Correct Answer: D

Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.

Question 2 of 5

A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

Correct Answer: D

Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.

Question 3 of 5

The doctor has ordered an IV of magnesium sulfate for a G1 P0 with preeclampsia. Which of the following symptoms is an expected side effect of magnesium sulfate?

Correct Answer: C

Rationale: Hyporeflexia is an expected side effect of magnesium sulfate, used to monitor for toxicity in preeclampsia treatment.

Question 4 of 5

The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

Correct Answer: D

Rationale: A 30 month-old only drinking from a sippy cup. A 30 month-old should be able to drink from a cup without a cover.

Question 5 of 5

The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma exacerbation? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Severe asthma exacerbations cause accessory muscle use, chest tightness, high-pitched wheezing, and tachypnea due to airway obstruction. Prolonged expiration, not inspiration, is typical as air is trapped.

Similar Questions

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
The nurse enters a client’s room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene?
A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?

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