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Questions 148

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Question 1 of 5

A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?

Correct Answer: D

Rationale: Pain (
D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (
A), vital signs (
B), and oxygen saturation (
C) are secondary.

Question 2 of 5

A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?

Correct Answer: C

Rationale: An unusual swelling pattern after removing an elastic wrap suggests incorrect wrap technique (
C), which can cause uneven pressure. Infection (
A), impaired circulation (
B), or bleeding (
D) would present differently.

Question 3 of 5

Which of the following signs and symptoms would a nurse expect when examining a 22-year-old female with secondary syphilis?

Correct Answer: C

Rationale: Secondary syphilis presents with a non-itchy rash, often on the palms and soles. Chancres are primary syphilis, and skin tumors are tertiary syphilis.

Question 4 of 5

The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:

Correct Answer: B

Rationale: Guillain-Barre syndrome typically shows elevated protein levels in cerebrospinal fluid with a normal cell count, known as albuminocytologic dissociation.

Question 5 of 5

The physician has ordered injections of Neumega (oprellvekin) for a client receiving chemotherapy for prostate cancer. Which finding suggests that the medication is having its desired effect?

Correct Answer: B

Rationale: Neumega (oprelvekin) stimulates platelet production, so a platelet count of 250,000 mm³ indicates effectiveness.

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