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Questions 149

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Extract:


Question 1 of 5

A 32-year-old male client has just undergone a liver biopsy and is released to the post-op floor for observation. The nurse should have the client lie in what position?

Correct Answer: B

Rationale: Lying on the right side applies pressure to the liver biopsy site, reducing bleeding risk.

Question 2 of 5

A client with severe anemia is to receive a unit of whole blood. In the event of a transfusion reaction, the first action by the nurse should be to:

Correct Answer: B

Rationale: Stopping the transfusion and maintaining an IV of normal saline is the first action to prevent further reaction and stabilize the client.

Question 3 of 5

The client with a pacemaker should be taught to:

Correct Answer: D

Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.

Question 4 of 5

A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?

Correct Answer: C

Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.

Question 5 of 5

A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?

Correct Answer: C

Rationale: A pH of 7.23 indicates severe respiratory acidosis due to CO2 retention, a sensitive indicator for mechanical ventilation need in COPD. PCO2 and HCO3 are less immediate, and SaO2 is not critical.

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