Question

A nurse is caring for a client who is in active labor.

Answer 1

Correct Answers

Decrease the IV flow rate. [ Contraindication ]
Monitor fetal heart rate [ Essential ]
Administer ampicillin IV [ Essential ]
Place client in left lateral position [ Essential ]
Request a prescription for ephedrine. [ Essential ]

Rationale :

✔️ Decreasing IV fluids after an epidural can worsen hypotension, a common side effect.

✔️ Fetal heart rate monitoring is crucial as the epidural can affect uteroplacental perfusion.

✔️ Ampicillin is indicated for GBS-positive status to prevent neonatal sepsis.

✔️ Left lateral positioning improves uteroplacental perfusion and decreases the risk of hypotension.

✔️ Ephedrine is the drug of choice to treat maternal hypotension following an epidural.

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Answer 2

Correct Answers:

The child was brought to the ED 2 days after the injury occurred.

Rationale :

🔶 Delay in seeking treatment raises concerns for possible abuse or neglect.

🔶 Injuries like fractures usually prompt immediate medical attention; delay can be a red flag.

🔶 Inconsistent timelines or stories are common patterns in child maltreatment.

🔶 Child protection guidelines require prompt reporting of delayed injury care.

🔶 Further investigation is necessary to rule out non-accidental trauma.

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Answer 3

Correct Answers:

Select a site proximal to previous venipuncture sites.

Rationale :

🔷 Using a proximal site ensures improved flow and avoids infiltrated/damaged veins.

🔷 Distal-to-proximal rule: if one site fails, go above it—not below.

🔷 Initiating an IV near old sites increases the risk of infiltration or vein rupture.

🔷 This site also allows for better administration of medications or fluids.

🔷 Palmar and wrist areas are painful and high-movement areas, making them unsuitable.

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Answer 4

Correct Answers:

Position the client on their side.

Rationale :

💠 Positioning on the side prevents aspiration of secretions during the postictal phase.

💠 Airway is a priority post-seizure; side-lying promotes airway patency.

💠 This position facilitates drainage of saliva or vomit, preventing hypoxia.

💠 Client may be confused; restraint or walking is unsafe immediately post-seizure.

💠 Side-lying reduces the risk of tongue obstruction of the airway.

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Answer 5

Correct Answers:

Acute hemolytic

Rationale :

♦ Fever, chills, low-back pain, and chest tightness are hallmark signs of acute hemolytic reaction.

♦ This is a medical emergency due to RBC destruction from ABO incompatibility.

♦ Symptoms typically appear within the first 15 minutes of transfusion.

♦ Immediate discontinuation of transfusion and emergency care is warranted.

♦ Other reactions (allergic or febrile nonhemolytic) do not typically present with chest or lumbar pain.

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Answer 6

Correct Answers:

Instruct the client to bear down when the speculum is inserted.

Rationale :

🟢 Bearing down relaxes pelvic muscles, easing speculum insertion and reducing discomfort.

🟢 A full bladder may cause discomfort or impede visualization during the exam.

🟢 Breathing normally helps relax the client; breath-holding increases muscle tension.

🟢 The correct position for pelvic exams is lithotomy, not Sims’.

🟢 Client cooperation and positioning enhance effectiveness and comfort during the procedure.

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Answer 7

Correct Answers:

"Do you ever think about harming yourself?"

Rationale :

⚫ The priority is to assess for suicide risk when a client expresses feelings of uselessness.

⚫ According to Maslow’s hierarchy, safety needs come before psychosocial concerns.

⚫ Depression in older adults may manifest as hopelessness or self-neglect.

⚫ This direct questioning is clinically appropriate and does not encourage suicidal ideation.

⚫ If risk is identified, the nurse can initiate mental health interventions.

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Answer 8

Correct Answers:

Nervousness

Rationale :

🔴 A glucose level of 64 mg/dL indicates mild hypoglycemia, which often causes nervousness or tremors.

🔴 Other early signs include diaphoresis, anxiety, and irritability.

🔴 Tachypnea and ketonuria are signs of hyperglycemia or DKA, not hypoglycemia.

🔴 Warm skin is not a typical feature of low blood sugar; usually, skin is cool and clammy.

🔴 Early detection of symptoms allows prompt correction with carbohydrates.

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Answer 9

Correct Answers:

Fever

Rationale :

🟣 Clozapine can cause agranulocytosis, and fever is an early sign of this life-threatening condition.

🟣 WBC suppression leads to increased risk of infection, requiring immediate discontinuation.

🟣 Fever in a client on clozapine must be reported immediately to avoid septic progression.

🟣 Other side effects (diaphoresis, polyuria) are less severe and not linked to agranulocytosis.

🟣 Monitoring CBC and WBC counts is standard protocol with clozapine.

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Answer 10

Correct Answers:

"Apply the patchprior to traveling."

Rationale :

🟠 Scopolamine patches should be applied 4 hours before travel for optimal effectiveness.

🟠 Patches are applied behind the ear, not on the arm.

🟠 Once removed, a patch should not be reused; reapplying it to the same spot is discouraged.

🟠 Patches should be stored at room temperature, not refrigerated.

🟠 Teaching proper timing enhances therapeutic outcome and symptom prevention.

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options	Essential	Contraindication
Decrease the IV flow rate.
Monitor fetal heart rate
Administer ampicillin IV
Place client in left lateral position
Request a prescription for ephedrine.

QLexNursing

1 :
A nurse is caring for a client who is in active labor.

Correct Answers

2 :
A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

3 :
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

5 :
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

6 :
A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

7 :
A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

8 :
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?

9 :
A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

10 :
A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?

QLexNursing

1 : A nurse is caring for a client who is in active labor.

Correct Answers

2 : A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

3 : A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

4 : A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

5 : A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

6 : A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

7 : A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

8 : A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?

9 : A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

10 : A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?

1 :
A nurse is caring for a client who is in active labor.

2 :
A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

3 :
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

5 :
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

6 :
A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

7 :
A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

8 :
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?

9 :
A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

10 :
A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?