Extract:

Question 1 of 5

You are caring for a high risk pregnant client who is in a life threatening situation. The fetus is also at high risk for death. Clinical decisions are being made that concern you because some of these treatments and life saving measures promote the pregnant woman's life at the same time that they significantly jeopardize the fetus' life and viability and other decisions can preserve the fetus's life at the expense of the pregnant woman's life. Which role of the nurse is the priority at this time?

Correct Answer: D

Rationale: In this complex ethical situation, the nurse's priority role is advocacy . Advocacy involves ensuring that the client's rights, values, and preferences are respected, especially in life-threatening situations with conflicting clinical decisions. The nurse must advocate for informed decision-making, ensuring the client understands the risks and benefits to both herself and the fetus, and support her autonomy in decision-making.

Question 2 of 5

A client with a history of depression is prescribed mirtazapine (Remeron). The nurse should monitor the client for which of the following adverse effects?

A. Weight gain. B. Hypoglycemia. C. Bradycardia. D. Hypotension.

Correct Answer: A

Rationale: Mirtazapine commonly causes weight gain.

Question 3 of 5

The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.

A. Encourage the client to cough and deep breathe. B. Add water to the suction chamber as it evaporates. C. Keep the collection chamber below the client's waist. D. Clamp the chest tube when the client gets out of bed. E. Tape the connection between the chest tube and the drainage system.

Correct Answer: A,B,C,E

Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.

Question 4 of 5

The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?

A. Normal sinus rhythm. B. Sinus tachycardia. C. Atrial fibrillation. D. Ventricular tachycardia.

Correct Answer: C

Rationale: Without the strip, atrial fibrillation is assumed for its common occurrence and need for monitoring in a test context.

Question 5 of 5

When creating a program to decrease the primary cause of disability and death in children, which of the following is most effective for the community health nurse to do?

A. Encourage state legislators to draft legislation to promote prenatal care. B. Recommend that the health department make immunizations available at no cost to all children. C. Teach health and safety practices to children and their parents. D. Have a nurse practitioner hired for each of the schools in the community.

Correct Answer: B

Rationale: Free immunizations address the leading cause of preventable childhood disability and death by ensuring widespread protection against infectious diseases.