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Questions 164

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Question 1 of 5

A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?

Correct Answer: B

Rationale: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.

Question 2 of 5

The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?

Correct Answer: A

Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.

Question 3 of 5

A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report:

Correct Answer: A

Rationale: Erythropoietin can increase blood viscosity, raising the risk of hypertension or thrombosis, which may present as a severe headache. Slight nausea , decreased urination , and itching are less specific or urgent.

Question 4 of 5

The client is receiving furosemide (Lasix) 80 mgm. Which is a sign of a possible complication of the administration of furosemide?

Correct Answer: A

Rationale: Furosemide is a loop diuretic that can cause electrolyte imbalances, such as hypokalemia, which may lead to tachycardia. Hypertension is not a common complication; polyuria is an expected effect, not a complication; and eupnea (normal breathing) is unrelated.

Question 5 of 5

The nurse is caring for an older adult client who has experienced recent multiple falls and weight loss. The client lives with an adult child, but the nurse is questioning the safety of the home. Which of the following interdisciplinary team members would be most appropriate for the nurse to consult?

Correct Answer: C

Rationale: A social worker can assess the home environment, coordinate resources for safety modifications, and address caregiving concerns, making them the most appropriate consult for home safety evaluation.

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