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Questions 149

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Question 1 of 5

A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?

Correct Answer: C

Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.

Question 2 of 5

A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is

Correct Answer: A

Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.

Question 3 of 5

A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?

Correct Answer: D

Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.

Question 4 of 5

Damage to the VII cranial nerve results in:

Correct Answer: C

Rationale: The VII cranial nerve (facial nerve) controls facial muscles; damage causes facial paralysis, affecting eye movement (e.g., inability to close the eye).

Question 5 of 5

Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter?

Correct Answer: A

Rationale: The Trendelenburg position increases venous filling in the upper body, making the subclavian or jugular veins easier to access for catheter insertion.

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