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Q&A Priority

Q&A Priority

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Question Number 1 of 25
The nurse assesses several post partum women in the clinic. Which of the following women is athighest risk for
puerperal infection?

The correct response is"C ".
A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
B) 2 days post partum, temperature of 101.2 degrees Farenheit this morning
C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days
D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery

Your response was" B".
The correct answer is C: 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days
A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth,

constitutes a post partum infection.
Question Number 2 of 25
A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following
is appropriate reinforcement of information by the nurse?

The correct response is"A ".
A) "Drink at least 8 glasses of water a day."
B) "Be sure to take the medication with food."
C) "It is safe to take with oral contraceptives."
D) "Stop the medication after 5 days."

Your response was" A".
The correct answer is A: "Drink at least 8 glasses of water a day."
Bactrim is a highly insoluble drug and requires a large volume of fluid intake. Taking with food is not necessary. Options 3

and 4 are incorrect instructions with use of bactrim
Question Number 3 of 25

A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees
Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which
assessment would have alerted the nursefirst to the client's change in condition?

The correct response is"B ".
A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature

Your response was"C".
The correct answer is B: Respiratory rate
Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for

decreased oxygenation is increased respiratory rate.
Question Number 4 of 25
A client calls the evening health clinic to state \u201cI know I have a severely low sugar since the Lantus insulin was given 3
hours ago and it peaks in 2 hours.\u201d What should be the nurse\u2019sinitial response to the client?

The correct response is"B ".
A) What else do you know about this type of insulin?
B) What are you feeling at this moment?
C) Have you eaten anything today?
D) Are you taking any other insulin or medication?

Your response was" B".
The correct answer is B: What are you feeling at this moment? When a client has changed from stable to unstable the
initial response is to do further assessment of the client.
Question Number 5 of 25
The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been
prescribed. Today's prothrombin level is 40 (normal range 10-14). Which of the following is a priority assessment?
The correct response is"A ".
A) Neurological signs
B) Lung sounds
C) Homan's sign
D) Gum bleeding
Your response was" B". The correct answer is A: Neurological signs
Question Number 6 of 25
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
The correct response is"C ".

A) Obtain emergency equipment
B) Assess heart rate, rhythm and all pulses
C) Apply pressure to the vessel insertion site
D) Use cold packs at the exit incision site

Your response was"C".
The correct answer is C: Apply pressure to the vessel insertion site If a central venous catheter is accidentally removed,
pressure should be applied to the vein entry site assessments are a priority in this post-CVA client
Question Number 8 of 25
Before administering a feeding through a gastrostomy tube, what is thepriorit y nursing assessment?
The correct response is"D ".

A) Measure the vital signs
B) Palpate the abdomen
C) Assess for breath sounds
D) Verify tube patency

Your response was"D".
The correct answer is D: Verify tube patency Tube patency should be checked prior to all feedings. The feeding should not
be attempted if the tube is not patent
Question Number 9 of 25

During a fluid exchange for the client who is 48 hours post insertion of the abdominal Tenckhoff catheter for peritoneal
dialysis, the nurse knows that the appearance of which of the following needs to be reported to the health care provider
immediately?
The correct response is"D ".

A) Slight pink - tinged drainage
B) Abdominal discomfort
C) Muscle weakness
D) Cloudy drainage
Your response was"C".
The correct answer is D: Cloudy drainage Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation
of the peritoneum). Other options are expected side effects of peritoneal dialysis.
Question Number 10 of 25
A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse questionf irst?
The correct response is"C ".

A) repeat glycohemoglobin in 24 hours
B) document accuchecks, intake and output every 4 hours
C) humulin N 20 units IV push
D) IV fluids of 0.9% normal saline at 125 ml per hour

Your response was"C".

The correct answer is C: humulin N 20 units IV push Regular insulin is the only insulin that can be given by the
intravenous route. This is the initial order to question. Another order to question is option 1 although it is not a priority
since the client would not be harmed by this action. This lab test gives the average glucose on the hemoglobin molecule

for the past 2 to 3 months. There would be no need to repeat it at this time. A fasting glucose in the morning would be
more appropriate to obtain. The other orders are within expected actions in this situation.
Question Number 11 of 25
The nurse is caring for a client who is receiving total parenteral nutrition (hyperalimentation and lipids). What is the priority
nursing action on every 8 hour shift?

The correct response is"C ".
A) Monitor blood pressure, temperature and weight
B) Change the tubing under sterile conditions
C) Check urine glucose, acetone and specific gravity
D) Adjust the infusion rate to provide for total volume

Your response was" B".
The correct answer is C: Check urine glucose, acetone and specific gravity
Because of the high dextrose and protein content in parenteral nutrition, the nurse should assess the urine at least every

8 hours
Question Number 12 of 25
The nurse is caring for a client on complete bed rest. Which action by the nurse ismost important in preventing the
formation of deep vein thrombosis?
The correct response is"D ".

A) Elevate the foot of the bed
B) Apply knee high support stockings
C) Encourage passive exercises
D) Prevent pressure at back of knees

Your response was"C".
The correct answer is D: Prevent pressure at back of knees
Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York:

Delmar
Question Number 13 of 25
What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline
(Pamelor)?
The correct response is"B ".

A) Symptom relief occurs in a few days
B) Alcohol use is to be avoided
C) Medication must be stored in the refrigerator
D) Episodes of diarrhea can be expected

Your response was" B".
The correct answer is B: Alcohol use is to be avoided
Alcohol potentiates the action of tricyclic antidepressants

Question Number 14 of 25
A client returns from the operating room after a right orchiectomy. For the immediate post operative period the nursing
priority would be to

The correct response is"B ".
A) Maintain fluid and electrolyte balance
B) Manage post operative pain
C) Ambulate the client within 1 hour of surgery
D) Control bladder spasms

Your response was" A".

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