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Questions 164

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Question 1 of 5

A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

Correct Answer: D

Rationale: Remove the child's toys from the immediate area. Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child's mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.

Question 2 of 5

The nurse reinforces teaching for a client taking atorvastatin to call the health care provider if experiencing which symptom associated with a serious adverse effect of the medication?

Correct Answer: C

Rationale: Muscle aches may indicate myopathy or rhabdomyolysis, serious atorvastatin side effects requiring immediate attention. Diarrhea, headaches, and numbness are less specific or unrelated.

Question 3 of 5

While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?

Correct Answer: A

Rationale: Respiratory rate of 42. An elevated respiratory rate indicates potential airway obstruction, requiring urgent intervention.

Question 4 of 5

The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is

Correct Answer: C

Rationale: Cardiac output altered: decreased. Increasing cardiac output is the primary goal of therapy, improving comfort and respiratory status.

Question 5 of 5

An adult asks the nurse what could be causing him to have a black tongue and black stools. The following items are in the client's history. Which is most likely to be causing his symptoms?

Correct Answer: A

Rationale: Bismuth subsalicylate commonly causes black tongue and stools, a harmless side effect, unlike the other options.

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