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Questions 164

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Question 1 of 5

A client with acquired immunodeficiency syndrome is admitted with a diagnosis of pneumocystis jirovecki pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based on his mental status, the priority nursing diagnosis is:

Correct Answer: B

Rationale: The client's confusion and attempts to remove medical devices indicate a risk for self-injury, making this the priority nursing diagnosis.

Question 2 of 5

Prior to discharge from the postanesthesia care unit following a vein stripping of the left leg, the nurse should tell the client to:

Correct Answer: B

Rationale: Elevating legs or walking promotes venous return, while avoiding prolonged standing/sitting prevents stasis post-vein stripping. Heat, non-weight bearing, and early bandage removal are not recommended.

Question 3 of 5

The nurse is caring for a client who has a pulmonary embolism. Which of the following findings would the nurse expect to observe? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Pulmonary embolism obstructs pulmonary arteries, causing dyspnea, chest pain, tachypnea, and hypoxemia. Bradycardia is unlikely; tachycardia is typical. Tracheal deviation is associated with tension pneumothorax, not embolism.

Question 4 of 5

The nurse is experiencing repeated unwanted sexual advances from a health care provider (HCP). Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Seeking support aids coping, reviewing policy clarifies procedures, reporting to a supervisor initiates formal action, and documentation provides evidence. Confronting outside work risks escalation and is unsafe.

Question 5 of 5

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.

Correct Answer: C,D,E

Rationale: Rosuvastatin, a statin, is expected to lower LDL cholesterol, total cholesterol, and triglycerides, indicating therapeutic response. An increase in alanine aminotransferase suggests liver stress, which is a side effect to monitor, not a therapeutic goal. A decrease in HDL cholesterol is undesirable, as statins typically maintain or increase HDL.

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