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Questions 158

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Question 1 of 5

A client with a history of chronic kidney disease is admitted with complaints of shortness of breath. The nurse should give priority to:

Correct Answer: A

Rationale: Shortness of breath in chronic kidney disease may indicate fluid overload, so administering diuretics is the priority.

Question 2 of 5

Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?

Correct Answer: D

Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.

Question 3 of 5

The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

Correct Answer: C

Rationale: Neonates of diabetic mothers are often large for gestational age (macrosomic) due to maternal hyperglycemia and are at risk for hypoglycemia after birth due to high insulin levels. Hyperglycemia and small size are less common.

Question 4 of 5

A client with polycythemia vera is admitted with complaints of difficulty breathing and pleuritic pain. Which lab finding is expected in the client with polycythemia vera?

Correct Answer: A

Rationale: Polycythemia vera is characterized by excessive red blood cell production, leading to an increased red blood cell count, which can cause hyperviscosity and symptoms like dyspnea.

Question 5 of 5

A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:

Correct Answer: A

Rationale: The water seal prevents air from entering the pleural space, maintaining negative pressure for lung re-expansion.

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