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Questions 158

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Extract:


Question 1 of 5

A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, 'Oh dear, I feel like I have to urinate again!' Which of the following is the most appropriate initial nursing response?

Correct Answer: B

Rationale: The most frequent reason for an urge to void with an indwelling catheter is blocked tubing, so checking the catheter's patency is the best initial response.

Question 2 of 5

The nurse is caring for a client with a history of a pulmonary embolism who is receiving Warfarin (Coumadin). The nurse should monitor the client for:

Correct Answer: A

Rationale: Warfarin, an anticoagulant, increases bleeding risk, requiring monitoring for signs like epistaxis or hematuria. Hypertension, tachypnea, and fever are not primary concerns.

Question 3 of 5

The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?

Correct Answer: C

Rationale: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.

Question 4 of 5

A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?

Correct Answer: B

Rationale: These symptoms are found in clients with tardive dyskinesia.

Question 5 of 5

Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?

Correct Answer: B

Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.

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