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Question 1 of 5

A client is to wear a Holter monitor for continuous cardiac monitoring for 48 hours. The nurse should advise the client to avoid which of the following activities during the monitoring period? Select all that apply.

Correct Answer: C,D

Rationale: Holter monitors can be affected by electromagnetic interference from wireless devices like iPads (
C), so these should be avoided. Showering and bathing (
D) can damage the monitor or electrodes. Watching TV (
A), using a remote control (
B), drinking caffeine (E), and exercising (F) typically do not interfere with monitoring, though exercise should be noted in the activity log.

Question 2 of 5

The client with cancer refuses to care for herself. Which action by the nurse would be best?

Correct Answer: C

Rationale: Exploring the reason for the lack of motivation addresses the root cause, enabling tailored interventions to encourage self-care.

Question 3 of 5

After a train accident, the nurse is assigned to triage the injured. Based upon the triage protocol, which individual should be seen last?

Correct Answer: C

Rationale: Triage prioritizes life-threatening conditions. The 25-year-old with minor injuries (abrasion, swollen ankle) is the least urgent compared to potential cardiac, neurological, or traumatic injuries.

Question 4 of 5

A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication?

Correct Answer: B

Rationale: Increased thirst and urination suggest lithium toxicity, which can cause diabetes insipidus-like symptoms, requiring immediate attention.

Question 5 of 5

The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is:

Correct Answer: C

Rationale: The recommended suction pressure for adult tracheostomy is 80-120 mmHg to effectively remove secretions without causing trauma.

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The nurse is caring for a client with a closed head injury. A late sign of increased intracranial pressure is:
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Which of the following diet instructions should be given to the client with recurring urinary tract infections?

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