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Questions 149

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Question 1 of 5

A client develops anaphylaxis syndrome and loses consciousness after eating fruit salad containing kiwi fruit, to which the client is severely allergic. The nurse is aware that the initial concern is which of the following?

Correct Answer: A

Rationale: In anaphylaxis with unconsciousness, the initial priority is to establish a patent airway (
A) to ensure adequate oxygenation. Epinephrine (
D), oxygen (
C), and fluids (
B) follow but are secondary to airway management.

Question 2 of 5

The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last

Order the Items

Source Container

Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
Apply the irrigation sleeve over the stoma.
Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.

Correct Answer: E,D,C,B,A

Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.

Question 3 of 5

A client is receiving hospice and palliative care, including analgesia and other comfort measures. Which of the following indicates the client is undergoing life review? Select all that apply.

Correct Answer: A,C

Rationale: Looking at photos (
A) and reminiscing about parenting (
C) indicate life review, reflecting on past experiences. Other statements (B, D, E) relate to pain or end-of-life wishes.

Question 4 of 5

When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:

Correct Answer: C

Rationale: Elevating the hips relieves pressure on the prolapsed cord, maintaining fetal oxygenation.

Question 5 of 5

During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse's first action should be to:

Correct Answer: B

Rationale: A narcotic discrepancy requires reporting to the supervisor for investigation.

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