Extract:

Question 1 of 5

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician orders include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 mL/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should:

Correct Answer: A

Rationale: Increasing oxygen flow within the ordered range addresses increasing dyspnea and maintains oxygenation, which is the priority in suspected pulmonary embolism.

Question 2 of 5

Which of these clients is at greatest risk for falls?

A. A 77 year old female client in a client room that has low glare floors. B. An 87 year old female client in a client room that has low glare floors. C. A 27 year old sedated male client. D. A 37 year old male client with impaired renal perfusion.

Correct Answer: B

Rationale: An 87-year-old female is at the greatest risk for falls due to age-related factors like decreased mobility, balance issues, and potential comorbidities, compared to younger or less impaired clients.

Question 3 of 5

The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. The instillation is effective when:

A. The secretions are thinned. B. The client coughs. C. There is minimal friction when the catheter is passed into the tracheostomy tube. D. There is humidification for the respiratory tract.

Correct Answer: A

Rationale: Instilling normal saline thins secretions, facilitating effective suctioning of the tracheostomy tube.

Question 4 of 5

A 70-year-old, previously well client asks the nurse, 'I notice I have tremors. Is this just normal for my age?' The best response for the nurse to make is which of the following?

A. I wouldn't be worried because this is common with aging B. You should report this to the physician because it may indicate a problem C. You should drink orange juice when this occurs D. You should have your blood pressure checked when this occurs

Correct Answer: B

Rationale: Tremors in a 70-year-old are not necessarily normal and may indicate conditions like Parkinson's or medication side effects, requiring physician evaluation. Orange juice or blood pressure checks are not directly relevant.

Question 5 of 5

A client states she thinks she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about which of the following?

A. Menstrual cycle irregularity with increased menstrual flow B. Mood swings immediately after menses C. Tension and fatigue before menses and through the second day of the menstrual cycle D. Midcycle spotting and abdominal pain at the time of ovulation

Correct Answer: C

Rationale: PMS symptoms, such as tension and fatigue, typically occur before menses and may persist into the early menstrual phase. Irregular cycles, post-menses mood swings, or midcycle symptoms are less characteristic of PMS.