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Questions 158

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Question 1 of 5

A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:

Correct Answer: A

Rationale: Raising the head and placing feet in a dependent position reduces venous return and pulmonary congestion, addressing transfusion-related circulatory overload.

Question 2 of 5

A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?

Correct Answer: B

Rationale: Supine position provides access to the sternum for bone marrow aspiration. Dorsal recumbent (
A) is for abdominal exams, High Fowler’s (
C) is for breathing, and lithotomy (
D) is for pelvic procedures.

Question 3 of 5

When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:

Correct Answer: D

Rationale: Synthetic cast materials harden in 3-15 minutes. Weight bearing is permitted in 15-30 minutes. Drying time for plaster of Paris is about 24-72 hours. (B,
C) Plaster of Paris cast materials are heavier than synthetic materials and require a drying time of 24-72 hours. Synthetic materials dry within 30 minutes. Plaster of Paris cast materials are heavier than synthetic materials and require a longer period to set and dry. Even though setting time (hardening) is only 3-15 minutes, the drying time for plaster of Paris is 24-72 hours. This depends on the size and thickness of the cast, exposure to air, and humidity in the air.

Question 4 of 5

A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:

Correct Answer: A

Rationale: Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. Low-residue diets lead to constipation and are contraindicated in clients with diverticulosis. Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.

Question 5 of 5

A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:

Correct Answer: C

Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.

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