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Questions 149

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Question 1 of 5

A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?

Correct Answer: B

Rationale: Ineffective airway clearance is the priority post-laryngectomy due to the risk of mucus obstruction in the new airway (stoma), which can be life-threatening.

Question 2 of 5

The physician has ordered Vancocin (vancomycin) 500 mg IV every 6 hours for a client with MRSA. The medication should be administered:

Correct Answer: D

Rationale: Vancomycin should be infused over at least 60 minutes to prevent adverse reactions such as red man syndrome.

Question 3 of 5

The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:

Correct Answer: B

Rationale: Avoiding bending over prevents increased intraocular pressure post-cataract surgery.

Question 4 of 5

Which cephalic presentation is most common during delivery of a neonate?

Correct Answer: A

Rationale: Vertex presentation (
A), with the head flexed and occiput leading, is the most common (95%) during delivery.

Question 5 of 5

The nurse is giving an end-of-shift report when a client with a chest tube is noted in the hallway with the tube disconnected. What is the most appropriate action?

Correct Answer: B

Rationale: A disconnected chest tube risks air entering the pleural space, causing pneumothorax. Placing the end in sterile saline creates a water seal, preventing air entry until reconnection.

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