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Questions 149

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Extract:


Question 1 of 5

A client pushes his call light and tells the nurse his chest is hurting. The nurse sees his oxygen saturation is 88%. The nurse's first intervention is to

Correct Answer: B

Rationale: Hypoxemia (SpO2 88%) requires immediate oxygen administration to improve oxygenation, which is the priority for chest pain before further assessment or intervention.

Question 2 of 5

The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease). The nurse should give priority to:

Correct Answer: A

Rationale: Respiratory muscle weakness in ALS can lead to respiratory failure, making respiratory status assessment the priority.

Question 3 of 5

The nurse expects a child with a deficiency in factor VIII to be diagnosed with

Correct Answer: A

Rationale: Factor VIII deficiency causes hemophilia A, a bleeding disorder due to impaired clotting.

Question 4 of 5

An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help with decreasing the client's confusion by:

Correct Answer: D

Rationale: A nightlight reduces disorientation and confusion in elderly clients by providing visual cues in the dark.

Question 5 of 5

The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?

Correct Answer: A

Rationale: Hemolytic anemia causes red blood cell destruction, leading to bilirubin buildup and jaundice, which is specific to this type. Anorexia, tachycardia, and fatigue are nonspecific.

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