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Questions 149

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Question 1 of 5

A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?

Correct Answer: C

Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.

Question 2 of 5

A med-surg nurse is floating to the post-op floor for a few days. The float nurse sees one of the regular post-op nurses taking medication from the med cart and ingesting several pills. The float nurse should immediately

Correct Answer: B

Rationale: Reporting to the nursing supervisor ensures prompt investigation and intervention for suspected medication diversion, maintaining patient safety.

Question 3 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment

Question 4 of 5

The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:

Correct Answer: C

Rationale: Uremic frost, a powdery deposit on the skin, is associated with end-stage renal failure, not liver failure, but the options suggest a contextual error; renal failure is the intended association.

Question 5 of 5

A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.

Correct Answer: A,C

Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.

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