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Questions 160

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Extract:


Question 1 of 5

A client with a history of migraines reports an impending headache. Which nursing intervention is most appropriate?

Correct Answer: B

Rationale: A quiet, dark environment reduces stimuli that trigger or worsen migraines.

Question 2 of 5

A 6-year-old child has just had placement of bilateral myringotomy tubes. As the parents prepare for discharge, the nurse correctly includes which instruction in the child's discharge plan?

Correct Answer: C

Rationale: Earplugs prevent water entry during swimming or showering, reducing the risk of infection in ears with myringotomy tubes.

Question 3 of 5

The nurse observes a nursing assistant assigned to a client who just returned from having a bronchoscopy. Which action by the nursing assistant would prompt the nurse to intervene?

Correct Answer: B

Rationale: After a bronchoscopy, the client is at risk for airway compromise due to anesthesia or swelling. Offering water before the gag reflex returns can lead to aspiration, requiring intervention.

Question 4 of 5

A hospitalized client diagnosed with cancer has a sealed source of radiation inserted into the vagina. Which information is most important for the charge nurse to obtain to ensure the safety of the nurse assigned to care for the client?

Correct Answer: B

Rationale: Pregnancy contraindicates caring for clients with internal radiation due to fetal risk, making this the most critical information.

Question 5 of 5

Which assessment finding in a client with heart failure indicates fluid overload? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Weight gain, crackles, jugular vein distention, and peripheral edema are signs of fluid overload in heart failure.

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