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Questions 149

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Question 1 of 5

A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:

Correct Answer: C

Rationale: Protein-rich snacks help maintain nutritional status and support liver function in cirrhosis, while sodium should be limited to reduce ascites.

Question 2 of 5

The nurse is caring for a client with staphylococcus epidermidis. The client is on a vancomycin IV. What nursing consideration should the nurse be aware of regarding this medication?

Correct Answer: C

Rationale: Vancomycin requires monitoring trough levels (drawn before a dose) to ensure therapeutic efficacy and prevent toxicity.

Question 3 of 5

A client has been diagnosed with Parkinson disease and has been prescribed levodopa. Which of the following are contraindications to levodopa? Select all that apply.

Correct Answer: A,D

Rationale: Levodopa is contraindicated in narrow-angle glaucoma (
A) due to pupil dilation and melanoma (
D) due to potential tumor activation. Macular degeneration (
B), pregnancy (
C), and cataracts (E) are not contraindications.

Question 4 of 5

A client was transferred to the hospital unit as a direct admit from a small community hospital. While the nurse is obtaining part of the admission history information, the client suddenly becomes semiconscious. Assessment reveals a systolic BP of 70, heart rate of 130, and respiratory rate of 24. What is the nurse's initial action?

Correct Answer: B

Rationale: The client's symptoms suggest shock (low BP, high HR, elevated RR). Initiating an IV with a large bore needle allows for rapid fluid resuscitation, which is critical. Lowering the bed may worsen perfusion, notifying the physician delays action, and CPR is premature without pulselessness.

Question 5 of 5

An adolescent client is seen by the nurse at a school where a fatal shooting incident occurred on campus 3 months earlier. The nurse documents that the client is experiencing flashbacks, avoiding the location of the shooting, having angry outbursts, and experiencing a loss of interest in playing his favorite musical instrument. The nurse suspects the client is experiencing post-traumatic stress disorder. Which intervention would be the best for the nurse to implement?

Correct Answer: B

Rationale: Referring to the multidisciplinary crisis team ensures comprehensive, coordinated care for suspected PTSD, leveraging expertise beyond the nurse’s scope.

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