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Question 1 of 5

Which would be included in the nursing care plan of a client experiencing severe delirium tremens?

Correct Answer: B

Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.

Question 2 of 5

The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

Correct Answer: C

Rationale: Green-tinged amniotic fluid indicates meconium, a sign of fetal distress requiring immediate reporting.

Question 3 of 5

In many cultures, pregnancy is viewed as a natural rather than a medical condition. How does this affect prenatal care?

Correct Answer: A

Rationale: Viewing pregnancy as natural (
A) often leads to delayed or less frequent prenatal care, impacting monitoring. Harmful beliefs (
C) or increased mortality (
D) are not directly implied.

Question 4 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment

Question 5 of 5

The newly licensed nurse has been asked to perform a procedure that he feels unqualified to perform. The nurse's best response at this time is to:

Correct Answer: B

Rationale: Refusing and explaining the lack of qualification ensures patient safety and adheres to ethical standards.

Similar Questions

The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
The nurse is precepting a student nurse who is helping to care for a client with a hip fracture. The client has Buck's traction applied. Which statement by the student nurse indicates a need for further explanation by the primary nurse?
A client who has undergone a thyroidectomy complains of numbness, tingling, and stiffness in her hands, feet, and face as well as muscle tremors, spasmodic muscle contractions, and anxiety during the postoperative period. Which laboratory tests does the nurse anticipate that the physician will request?
The nurse is preparing to administer the first dose of IV antibiotic to the client. Halfway through the infusion, the nurse realizes that the antibiotic dosage is not the same as ordered by the health care provider. Which action should the nurse take first?
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.

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