a charge nurse on an obstetrical unit is preparing the shift assignment which of the following clients should be assigned to an rn who has floated fro

HESI LPN

Leadership and Management HESI Test Bank

1. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?

A. A client who is at 32 weeks of gestation and has premature rupture of membranes
B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
C. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
D. A client who has gestational diabetes and is receiving biweekly nonstress tests

Correct answer: C

Rationale: A nurse who floated from a medical-surgical unit would be appropriate to care for a client who is 1 day postoperative following a Cesarean section and has a PCA pump. This client requires monitoring of the postoperative incision site, pain management through the PCA pump, and assessment for any signs of complications related to the surgery. Assigning this client to an RN with experience in postoperative care aligns with providing specialized and appropriate care. Choices A, B, and D involve conditions or procedures specific to obstetrics that would be better managed by a nurse with obstetrical experience, making them incorrect choices for the floated RN.

2. What is an episiotomy?

A. A surgical incision of the perineum to prevent tearing during delivery.
B. Releasing the red plug from the cervix just before crowning occurs.
C. An incision in the abdomen with which the baby can be delivered through.
D. The severance of the umbilical cord between mother and child.

Correct answer: A

Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.

3. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

A. It is normal among adolescents.
B. It indicates that the patient has an intact peripheral nervous system.
C. It indicates that the patient has an intact central nervous system.
D. It is not a normal finding.

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

4. Which statement about appendicitis is accurate and true?

A. Appendicitis is more common among females than males.
B. A high fiber diet is a risk factor associated with appendicitis.
C. Left lower quadrant pain is suggestive of appendicitis.
D. McBurney's point tenderness is suggestive of appendicitis.

Correct answer: D

Rationale: The correct answer is D: McBurney's point tenderness is suggestive of appendicitis. McBurney's point is located in the right lower abdomen and tenderness at this point is a classic sign of appendicitis. Choice A is incorrect as appendicitis is slightly more common in males than females. Choice B is incorrect as a high fiber diet is actually considered to be protective against appendicitis. Choice C is incorrect as appendicitis typically presents with pain in the right lower quadrant, not the left.

5. What is the normal sodium level in the body?

A. 135 to 145 milliequivalents per liter.
B. 3 to 5 milliequivalents per liter.
C. 135 to 145 microequivalents per liter.
D. 3 to 5 microequivalents per liter.

Correct answer: A

Rationale: The correct answer is A: 135 to 145 milliequivalents per liter. The normal range for sodium levels in the body is expressed in milliequivalents per liter, not microequivalents. Choice B and D provide a significantly lower range which is not within the normal values for sodium. Choice C incorrectly states 'microequivalents' instead of the correct unit 'milliequivalents'. Therefore, A is the correct answer.