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Questions 158

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Question 1 of 5

A client with a history of a tonsillectomy is being discharged. The nurse should teach the client to:

Correct Answer: C

Rationale: Excessive swallowing post-tonsillectomy may indicate bleeding, a serious complication requiring immediate reporting. Gargling, cold liquids, and straws may irritate the surgical site.

Question 2 of 5

While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?

Correct Answer: C

Rationale: Warm sitz baths increase circulation, promote healing, and reduce edema in a traumatized perineum, making it appropriate for an ecchymotic area.

Question 3 of 5

Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?

Correct Answer: C

Rationale: Sulfasalazine commonly causes skin rash and diarrhea, which should be monitored. The other options are not relevant nursing implications.

Question 4 of 5

The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly--High risk for injury: Increased susceptibility to bleeding related to:

Correct Answer: B

Rationale: There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.

Question 5 of 5

The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

Correct Answer: C

Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (
A), wheezing (
B), and pain/rales (
D) are concerning but less urgent.

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