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Questions 149

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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 has had 4 pregnancies. She experienced one miscarriage at 12 weeks, had one stillborn birth at 34 weeks, a healthy son at 38 weeks, and a healthy daughter at 40 weeks. How would the client's obstetric history be classified?

Correct Answer: D

Rationale: Gravida 4 (4 pregnancies), Para 2 (2 viable births at 38 and 40 weeks). Miscarriage and stillbirth count as pregnancies but not viable births.

Question 3 of 5

The nurse is working with a nursing student to administer an enema solution to a client. The client states she feels painful cramping. The nurse should intervene by

Correct Answer: C

Rationale: Painful cramping during an enema suggests too-rapid administration. Clamping briefly and slowing the rate reduces discomfort.

Question 4 of 5

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

Correct Answer: A

Rationale: Cholinergic crisis, due to excessive acetylcholinesterase inhibitors, causes symptoms like constricted pupils and decreased blood pressure from parasympathetic overstimulation.

Question 5 of 5

The client with a pacemaker should be taught to:

Correct Answer: D

Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.

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