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Questions 158

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Question 1 of 5

A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:

Correct Answer: B

Rationale: Pulmonary contusions from blunt chest trauma cause alveolar edema and hemorrhage, leading to bloody sputum, hypoxemia, and patchy infiltrates on x-ray.

Question 2 of 5

The registered nurse is making assignments for the day. Which client should be assigned to the nurse who is pregnant?

Correct Answer: D

Rationale: Valganciclovir for cytomegalovirus poses minimal risk to a pregnant nurse as it is not teratogenic and standard precautions suffice. Pentamidine ribavirin and radium implants carry higher risks due to potential teratogenicity or radiation exposure.

Question 3 of 5

Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?

Correct Answer: C

Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (
C) assess for deterioration. Pain medication (
A), oxygen (
B), and Foley (
D) are secondary.

Question 4 of 5

A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:

Correct Answer: B

Rationale: An echocardiogram is non-invasive, requiring the client to lie still while cool gel is applied for ultrasound imaging, with no pain involved.

Question 5 of 5

Why is Phytonadione (vitamin K) administered to a newborn shortly after birth?

Correct Answer: D

Rationale: Newborns have low vitamin K levels, necessary for clotting factor synthesis. Phytonadione is given to facilitate clotting and prevent hemorrhagic disease of the newborn. It does not stop active hemorrhage, treat infections, or replace electrolytes.

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