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Questions 148

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Extract:


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

The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking lithium. Which of the following snacks would be best for the client with mania?

Correct Answer: C

Rationale: An apple is a healthy, low-sodium snack, suitable for a client on lithium, as high sodium foods like potato chips can affect lithium levels.

Question 3 of 5

The nurse should visit which of the following clients first?

Correct Answer: C

Rationale: Chest pain in a client with a history of angina suggests possible cardiac ischemia, requiring immediate assessment.

Question 4 of 5

Cystic fibrosis is an exocrine disorder that affects several systems of the body. The earliest sign associated with a diagnosis of cystic fibrosis is:

Correct Answer: D

Rationale: Meconium ileus, a bowel obstruction at birth, is often the earliest sign of cystic fibrosis in newborns.

Question 5 of 5

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Correct Answer: B

Rationale: The vital signs indicate shock, so contacting the physician for immediate intervention is the priority.

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