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Questions 149

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Extract:


Question 1 of 5

A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?

Correct Answer: B

Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury patients. Assessing and relieving the bladder is the priority after elevating the bed.

Question 2 of 5

The nurse is preparing to test a client who has the herpes virus. Which of the following tests should the nurse perform?

Correct Answer: C

Rationale: The Tzanck test is used to diagnose herpes virus infections by examining cells from a lesion for characteristic changes.

Question 3 of 5

The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:

Correct Answer: B

Rationale: Flushing the IV tubing with insulin and discarding the first 50 mL prevents insulin binding to the tubing, ensuring accurate dosing.

Question 4 of 5

An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client

Correct Answer: D

Rationale: prevents respiratory complications due to immobility following surgery

Question 5 of 5

The family of a hospice client wishes to visit at midnight. Which of the following actions by the nurse would be the most appropriate?

Correct Answer: D

Rationale: In hospice care, allowing family visits at any time supports the client’s and family’s emotional needs, especially near end-of-life.

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