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Questions 158

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Question 1 of 5

A client with a history of prostate cancer is admitted with complaints of bone pain. The nurse should give priority to:

Correct Answer: A

Rationale: Bone pain in prostate cancer often indicates bone metastasis, so monitoring for metastasis is the priority.

Question 2 of 5

The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)

Order the Items

Source Container

Client admitted from the emergency room previous shift with unrelieved migraine headache.
Client transferred from surgical intensive care after traumatic brain injury. Pulse oximetry reading 94%.
Client with a Glasgow coma scale (GCS) of 5 with evidence of cerebral aneurysm rupture on CT scan.
Client admitted from the emergency room after a motor vehicle accident and GCS of 13

Correct Answer: C, B, D, A

Rationale: Priority: GCS 5 with aneurysm (
C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).

Question 3 of 5

The client is prescribed levothyroxine (Synthroid) for hypothyroidism. Which instruction should the nurse include?

Correct Answer: B

Rationale: Levothyroxine can cause cardiac side effects like palpitations or chest pain, which should be reported. It is taken in the morning, fiber is not directly related, and food reduces absorption.

Question 4 of 5

A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:

Correct Answer: B

Rationale: Supplemental O2 should be administered before and after suctioning to reduce hypoxia.

Question 5 of 5

During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:

Correct Answer: D

Rationale: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.

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