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Questions 149

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Extract:


Question 1 of 5

A client has just finished her lunch, consisting of shrimp with rice, fruit salad, and a roll. The client calls for the nurse, stating, 'My throat feels thick and I'm having trouble breathing.' What action should the nurse implement first?

Correct Answer: C

Rationale: Symptoms suggest an allergic reaction, possibly anaphylaxis from shrimp. Placing the client in high Fowler's position facilitates breathing, and calling the physician ensures rapid intervention.

Question 2 of 5

A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?

Correct Answer: C

Rationale: A pH of 7.23 indicates severe respiratory acidosis due to CO2 retention, a sensitive indicator for mechanical ventilation need in COPD. PCO2 and HCO3 are less immediate, and SaO2 is not critical.

Question 3 of 5

The nurse is part of an interdisciplinary team in a rehabilitation unit. Which of the following statements by a client is most important to be communicated to the social worker on the team?

Correct Answer: A

Rationale: Inability to afford help (
A) is a social issue requiring the social worker's intervention for resources. Other concerns (B, C,
D) are addressed by therapy or nursing.

Question 4 of 5

The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:

Correct Answer: A

Rationale: The correct sequence is inspection, auscultation, palpation to avoid altering bowel sounds or causing discomfort during the exam.

Question 5 of 5

The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?

Correct Answer: A

Rationale: Cleansing the eye removes exudate, ensuring effective administration of eyedrops for conjunctivitis.

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