Extract:

Question 1 of 5

You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:

Correct Answer: B

Rationale: Wound dimensions are typically documented as length x width x depth (2 cm x 4 cm x 3 cm), but based on options, 12 cm may reflect a calculation error; correct documentation is individual measurements.

Question 2 of 5

The nurse is assessing a client with a suspected pulmonary embolism. Which of the following symptoms is most likely to be present?

A. Bradycardia. B. Sudden chest pain. C. Hypotension. D. Fever.

Correct Answer: B

Rationale: Sudden chest pain is a common symptom of pulmonary embolism due to impaired blood flow to the lungs.

Question 3 of 5

A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see fi gure). The nurse should do which of the following?

A. Reposition the infant to the left side. B. Ask the parents to put the infant back in his crib C. Remind the parents that the infant cannot use a pacifier now. D. Tell the parents they have positioned their infant correctly

Correct Answer: D

Rationale: Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a pacifi er if needed.

Question 4 of 5

The physician has ordered a low-potassium diet for a client. Which of the following food choices indicates that the client needs further instruction regarding the diet?

A. Apple. B. Baked potato. C. Carrots. D. Spinach.

Correct Answer: B

Rationale: Baked potatoes are high in potassium, so choosing them indicates a need for further teaching on a low-potassium diet.

Question 5 of 5

A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?

A. What has your neighbor been doing that bothers you?' B. How long have you been hearing these terrible voices?' C. I won't let your neighbor visit, so you'll be safe.' D. What exactly are these terrible voices saying to you?'

Correct Answer: D

Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.