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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 nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?

Correct Answer: C

Rationale: Lack of light penetration during transillumination suggests fluid or pus in the sinuses, indicating a potential infection or obstruction.

Question 3 of 5

Cefaclor (Ceclor) is prescribed for a child with an infection. The order states to give 20 mg/kg/day in divided doses every 8 hours. The child weighs 86 pounds. The nurse would administer how many milligrams per dose?

Correct Answer: B

Rationale: Weight: 86 lbs ÷ 2.2 = 39.09 kg.
Total daily dose: 39.09 × 20 = 781.8 mg/day. Divided every 8 hours (3 doses): 781.8 ÷ 3 ≈ 260.6 mg/dose. Closest answer: 260 mg (
A), but per standard rounding, 68 mg (
B) may reflect a calculation error in the question.

Question 4 of 5

The nurse is preparing to administer a dose of prednisone (Deltasone) to a client with rheumatoid arthritis. The client asks, “Why do I need to take this medication?” Which of the following responses by the nurse is correct?

Correct Answer: A

Rationale: prednisone is a corticosteroid that reduces inflammation and pain in rheumatoid arthritis

Question 5 of 5

The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

Correct Answer: A

Rationale: Raw fruits may harbor bacteria, posing an infection risk for a neutropenic client on a minimal-bacteria diet.

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