Question

A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

Answer 1

Correct Answers:

Use a sheet when repositioning the client onto his side.

Rationale :

🦴A client with a thoracic spine injury requires log-rolling using a draw sheet to maintain spinal alignment and prevent further injury.

💪The log-roll technique ensures that the head, neck, and spine move as one unit, reducing the risk of spinal cord compression.

⚕️Improper movement can cause displacement of vertebrae, worsening neurological damage or compromising stability.

👩‍⚕️Using a team approach during turning ensures safety and alignment throughout the procedure.

📌Core message

Use the log-roll method with a sheet to maintain spinal alignment and prevent cord injury.

Answer 2

Correct Answers:

Administer oxygen 10 L/min via nonrebreather mask

Rationale :

🌬️After a seizure, oxygenation is the top priority because maternal hypoxia can harm both mother and fetus.

💨Oxygen delivery via nonrebreather mask ensures high FiO₂ to improve tissue perfusion and prevent fetal distress.

🩺Once breathing stabilizes, the nurse can assess for uterine contractions or other complications.

⚕️Immediate oxygen supports recovery from eclamptic seizure and prevents secondary complications like hypoxic brain injury.

📌Core message

Post-seizure, prioritize oxygen administration to prevent hypoxia in mother and fetus.

Answer 3

Correct Answers:

Reinforce orientation to time, place. and person.
Establish eye contact when communicating with the client.
Give the client one simple direction at a time.

Rationale :

🧠Clients with dementia benefit from reorientation to maintain cognitive function and reduce confusion.

👁️Maintaining eye contact promotes trust and helps focus the client’s attention.

🗣️Giving simple, one-step directions reduces frustration and promotes comprehension.

⚕️Avoid overwhelming or contradicting the client, as refuting delusions can increase agitation.

📌Core message

Simple, direct communication and orientation reinforcement support dementia clients effectively.

Answer 4

Correct Answers:

Standard

Rationale :

🦠Erythema migrans is the characteristic rash of Lyme disease, caused by Borrelia burgdorferi transmitted by tick bites.

🧤The infection is not transmitted person to person, so standard precautions are sufficient.

⚕️These include hand hygiene and glove use when handling body fluids or open skin.

🚫Contact, droplet, or airborne isolation is unnecessary for this condition.

📌Core message

Lyme disease requires only standard precautions since it’s not contagious between people.

Answer 5

Correct Answers:

Diaphoresis
Tremors
Inability to concentrate

Rationale :

🩸Hypoglycemia triggers a sympathetic nervous system response, causing sweating (diaphoresis) and tremors.

🧠Low glucose impairs brain function, leading to difficulty concentrating or confusion.

🍬These symptoms signal the need for prompt carbohydrate intake to restore glucose levels.

🚨Polydipsia and acetone odor indicate hyperglycemia, not hypoglycemia.

📌Core message

Sweating, tremors, and confusion are hallmark signs of hypoglycemia.

Answer 6

Correct Answers:

Provide the client with a stool softener.

Rationale :

🩸Thrombocytopenia increases the risk of bleeding from minor trauma or straining.

🚽Stool softeners prevent constipation and reduce the need for straining, which can cause rectal bleeding.

⚕️Avoiding invasive procedures or irritants protects mucous membranes and prevents bleeding.

🌸This measure minimizes hemorrhage risk without compromising bowel health.

📌Core message

Use stool softeners to prevent bleeding from straining in thrombocytopenia.

Answer 7

Correct Answers:

“It will apply an external fetal heart rate monitor during the test.”

Rationale :

🩺A contraction stress test (CST) evaluates fetal well-being by monitoring heart rate in response to contractions.

📊External fetal monitoring records the baby’s heart rate and uterine activity simultaneously.

⚕️The goal is to identify late decelerations, indicating possible uteroplacental insufficiency.

💬Other options like medications or oxygen are not part of the CST procedure.

📌Core message

A CST uses external fetal heart rate monitoring to assess placental function and fetal tolerance.

Answer 8

Correct Answers:

Determine if the tablets are scored.

Rationale :

💊Only scored tablets can be safely divided because they ensure equal distribution of medication in each half.

⚕️Unscored or extended-release tablets must not be cut due to altered absorption or dosing error.

🧠Verification prevents under-dosing or overdosing, maintaining therapeutic effectiveness.

👩‍⚕️The nurse ensures safe administration by checking manufacturer instructions before advising the client.

📌Core message

Only scored tablets should be split safely to ensure accurate dosing.

Answer 9

Correct Answers

Blank 1 Correct Option: thoughts of self harm
Blank 2 Correct Option: hopelessness

Rationale :

🧠A client expressing hopelessness, withdrawal, and loss of appetite after significant stressors is at high risk for self-harm.

💬Statements like “My life is a mess” indicate despair and suicidal ideation, requiring immediate intervention.

⚕️Clients with major depressive disorder and family history are especially vulnerable to self-injury.

🚨Nurses must implement suicide precautions and notify the provider immediately.

📌Core message

Hopelessness in major depression signals risk for self-harm, requiring urgent safety measures.

Answer 10

Correct Answers

Blank 1 Correct Option: opioid intoxication
Blank 2 Correct Option: pupil characteristics

Rationale :

🧠Opioid intoxication presents with miosis (pinpoint pupils), sedation, and respiratory depression, consistent with the client’s findings.

💉Naloxone administration and needle marks further confirm opioid use rather than alcohol intoxication.

🩺Depressed respiratory rate (10/min) and drowsiness are life-threatening features of overdose.

⚕️Immediate airway management and ongoing monitoring are critical for stabilization.

📌Core message

Pinpoint pupils and sedation confirm opioid intoxication, requiring respiratory support.

1 :
A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

2 :
A nurse observes a client who is at 37 weeks of gestation and has preeclampsia with severe features having a seizure. Which Of the following actions following the seizure should the nurse take first?

3 :
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

4 :
A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

5 :
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

6 :
A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

7 :
A nurse is teaching a client who is at 38 weeks of gestation about a contraction stress test. Which of the following statements should the nurse include in the teaching?

8 :
A home health nurse is verifying a client's prescribed medications and notes that one medication dose was decreased by half. The client asks the nurse if they can cut the tablets in half. Which of the following actions should the nurse take?

9 :
A nurse on a mental health unit is caring for a client

Correct Answers

10 :
A nurse is caring for a client in the emergency department.

Correct Answers

1 : A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

2 : A nurse observes a client who is at 37 weeks of gestation and has preeclampsia with severe features having a seizure. Which Of the following actions following the seizure should the nurse take first?

3 : A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

4 : A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

5 : A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

6 : A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

7 : A nurse is teaching a client who is at 38 weeks of gestation about a contraction stress test. Which of the following statements should the nurse include in the teaching?

8 : A home health nurse is verifying a client's prescribed medications and notes that one medication dose was decreased by half. The client asks the nurse if they can cut the tablets in half. Which of the following actions should the nurse take?

9 : A nurse on a mental health unit is caring for a client

Correct Answers

10 : A nurse is caring for a client in the emergency department.

Correct Answers

1 :
A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

2 :
A nurse observes a client who is at 37 weeks of gestation and has preeclampsia with severe features having a seizure. Which Of the following actions following the seizure should the nurse take first?

3 :
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

4 :
A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

5 :
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

6 :
A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

7 :
A nurse is teaching a client who is at 38 weeks of gestation about a contraction stress test. Which of the following statements should the nurse include in the teaching?

8 :
A home health nurse is verifying a client's prescribed medications and notes that one medication dose was decreased by half. The client asks the nurse if they can cut the tablets in half. Which of the following actions should the nurse take?

9 :
A nurse on a mental health unit is caring for a client

10 :
A nurse is caring for a client in the emergency department.