Question

A nurse is caring for a client in labor and delivery triage.

Answer 1

Correct Answers

Blank 1 Correct Option: Placental abruption
Blank 2 Correct Option: Administer IM betamethasone
Blank 3 Correct Option: Contraction pattern and Cervical dilation

Rationale :

🔷 Placental abruption refers to the premature separation of the placenta from the uterine wall, which can compromise fetal oxygenation and lead to preterm labor or fetal distress.

🔷 The client's symptoms—dark red vaginal bleeding, uterine tenderness, contractions every 4–8 minutes, and cervical dilation with effacement—strongly support this diagnosis over others like placenta previa or preterm labor alone.

🔷 Administering IM betamethasone at 24 weeks gestation is indicated because it promotes fetal lung maturity, reducing the risk of respiratory distress syndrome if preterm delivery occurs.

🔷 Monitoring contraction patterns is essential to assess the frequency, duration, and intensity of uterine activity, which reflects the risk of ongoing labor or worsening abruption.

🔷 Cervical dilation and effacement should be monitored closely because changes can indicate labor progression, influencing decisions regarding maternal-fetal stabilization or possible delivery.

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Answer 2

Correct Answers

Lymphadenopathy [ German measles (Rubella) ]
Red rash on the face [ Fifth disease (Erythema infectiosum) ]
Fever [ Measles (Rubeola) ]
White spots on the buccal mucosa [ Measles (Rubeola) ]

Rationale :

🔶 Lymphadenopathy (particularly postauricular and suboccipital) is a hallmark of rubella (German measles).

🔶It often presents before or during the appearance of a fine pink rash and is a distinguishing feature among pediatric viral exanthems.

🔶 A red rash on the face is shared across fifth disease, measles, and rubella.

🔶 In fifth disease, it's described as a “slapped cheek” appearance. In measles, the rash begins on the face and spreads downward. In rubella, it is typically lighter and shorter in duration.

🔶 Fever is most consistently elevated in measles (rubeola), often spiking to over 104°F, and is part of the prodrome that includes cough, coryza, and conjunctivitis.

🔶 White spots on the buccal mucosa are known as Koplik spots, which are pathognomonic for measles.

🔶They typically appear 1–2 days before the skin rash and are located near the molars.

🔶 This pattern of findings—fever, lethargy, Koplik spots, rash—strongly aligns with measles, while some features like rash and lymphadenopathy also cross into rubella and fifth disease.

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Answer 3

Correct Answers:

Wash the area around the base of the cord With water.

Rationale :

🟢 Keeping the umbilical cord area clean and dry is essential to promote natural drying and falling off of the stump.

🟢 Use plain water and gently pat the area dry; no alcohol or ointments are recommended unless prescribed.

🟢 Do not cover the stump with the diaper—fold the diaper below the stump to avoid irritation and promote airflow.

🟢 Minor bleeding is normal when the stump falls off, but continuous bleeding or signs of infection must be reported.

🟢 Petroleum jelly is not recommended, as it can keep the area moist and delay healing.

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Answer 4

Correct Answers:

"I will avoid crushing this medication."

Rationale :

🟣 Metformin extended-release (ER) tablets are formulated to release slowly, and crushing or chewing disrupts this mechanism, increasing side effects like GI upset or lactic acidosis risk.

🟣 ER formulations should be swallowed whole and taken with food to minimize GI discomfort.

🟣 Metformin is weight neutral or causes weight loss, not gain.

🟣 This teaching promotes safe administration practices and optimizes therapeutic effectiveness.

🟣 Taking it on an empty stomach is discouraged as it can lead to significant nausea or GI distress.

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Answer 5

Correct Answers:

Acute hemolytic reaction

Rationale :

🔴 Acute hemolytic transfusion reaction is a medical emergency and typically presents with chills, fever, low-back pain, chest tightness, and hypotension.

🔴 It results from ABO incompatibility, triggering immune destruction of donor RBCs.

🔴 Hemoglobinuria and renal failure can occur if not treated promptly.

🔴 The nurse should stop the transfusion immediately, maintain IV access with saline, and notify the provider.

🔴 This type of reaction can occur within minutes of starting the transfusion.

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Answer 6

Correct Answers:

Document in the client's medical record if the client has advance directives.

Rationale :

⚫ The Patient Self-Determination Act (PSDA) mandates that clients be informed of their rights to make advance healthcare decisions upon admission.

⚫ Nurses are required to ask about advance directives, provide information if requested, and document the client's response.

⚫ This ensures legal and ethical care planning, especially regarding life-sustaining treatments.

⚫ The act applies to all healthcare facilities that receive Medicare or Medicaid funding.

⚫ Ensuring documentation supports continuity of care and honors the client's autonomy.

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Answer 7

Correct Answers:

"I know the provider will replace the lens in my eyes during this procedure."

Rationale :

🟤 Cataract surgery involves removal of the clouded lens and implantation of an artificial intraocular lens (IOL).

🟤 The procedure is typically performed under local anesthesia with sedation, not general anesthesia.

🟤 Clients often regain clearer vision postoperatively with minimal discomfort.

🟤 Bruising of the eyelids and “seeing dark spots” are not common expectations; those should be reported if experienced.

🟤 Patient education should reinforce what to expect, such as avoidance of straining or rubbing the eye post-op.

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Answer 8

Correct Answers:

Herpes zoster.

Rationale :

⚪ The herpes zoster (shingles) vaccine is recommended for adults over 50 years to prevent shingles and postherpetic neuralgia.

⚪ DTaP, HPV, and rotavirus are pediatric vaccines and are not typically administered to older adults.

⚪ Shingles can be severe in older populations due to waning immunity.

⚪ Vaccination can reduce severity, duration, and complications associated with shingles.

⚪ The CDC recommends Shingrix (recombinant zoster vaccine) as the preferred vaccine.

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Answer 9

Correct Answers:

Abdominal distention

Rationale :

🟣 Paralytic ileus is a postoperative complication where intestinal peristalsis stops, leading to gas and fluid accumulation.

🟣 It is most commonly seen after abdominal or orthopedic surgery, especially with opioid use.

🟣 Abdominal distention, absent bowel sounds, and nausea are classic signs.

🟣 Watery stool may be misleading and indicate overflow from a blockage.

🟣 The nurse should report findings promptly to initiate bowel rest or NG decompression.

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Answer 10

Correct Answers:

"Prescribed dressing change was accidentally omitted during the previous shift."

Rationale :

🔵 Incident reports must be objective, factual, and nonjudgmental without assumptions or emotional wording.

🔵 This statement clearly states what occurred, avoids placing blame, and sticks to facts only.

🔵 Incident reports are not part of the medical record, so nothing about the form itself should be referenced there.

🔵 The priority is accurate documentation to support system improvement and patient safety.

🔵 The provider should be notified as soon as possible, not deferred.

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QLexNursing

1 :
A nurse is caring for a client in labor and delivery triage.

Correct Answers

2 :
A nurse is caring for an infant in an outpatient pediatrician's office.

Correct Answers

3 :
A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

4 :
A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

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 admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

7 :
A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

8 :
A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

9 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

10 :
A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

Assessment Finding	Fifth disease (Erythema infectiosum)	Measles (Rubeola)	German measles (Rubella)
Lymphadenopathy
Red rash on the face
Fever
White spots on the buccal mucosa

QLexNursing

1 : A nurse is caring for a client in labor and delivery triage.

Correct Answers

2 : A nurse is caring for an infant in an outpatient pediatrician's office.

Correct Answers

3 : A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

4 : A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

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 admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

7 : A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

8 : A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

9 : A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

10 : A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

1 :
A nurse is caring for a client in labor and delivery triage.

2 :
A nurse is caring for an infant in an outpatient pediatrician's office.

3 :
A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

4 :
A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

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 admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

7 :
A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

8 :
A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

9 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

10 :
A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?