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Questions 164

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Question 1 of 5

A 78-year-old client is admitted following a cerebrovascular accident. He cannot move his left arm and leg. Which finding would indicate to the nurse that the client also has homonymous hemianopia?

Correct Answer: B

Rationale: Homonymous hemianopia, a visual field defect from right brain stroke, causes left-sided vision loss, so the client misses the nurse on the left, unlike arm movement, swallowing, or speech issues.

Question 2 of 5

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding?

Correct Answer: B,D

Rationale: Cleansing the wound with normal saline (
B) removes contaminants, and hand hygiene with gloves (
D) ensures sterility. Applying ointment before the culture (
A) could contaminate the sample. Swabbing from the outermost margin to the center (E) risks contaminating the sample with skin flora; the correct method is to swab the cleanest area first. Obtaining drainage since the last dressing change (
C) may not target active infection.

Question 3 of 5

Following cardiac surgery, a client's urine output for the last hour is 20 mL. The nurse understands that this indicates which of the following?

Correct Answer: B

Rationale: Low urine output (20 mL/hour) post-cardiac surgery suggests insufficient cardiac output, impairing renal perfusion. Hyperkalemia, inadequate fluids, or diuresis are less likely causes without additional signs.

Question 4 of 5

A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which

Correct Answer: B

Rationale: lead to dehydration. The client must take in adequate fluids before and during exercise periods.

Question 5 of 5

The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum

Correct Answer: A

Rationale: Carpal spasm (Trousseau's sign) suggests hypocalcemia (
A), common in pancreatitis. Albumin (
B), troponin (
C), and potassium (
D) are unrelated to this finding.

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