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Questions 164

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Question 1 of 5

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.

Correct Answer: A,D,E

Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.

Question 2 of 5

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

Correct Answer: A

Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.

Question 3 of 5

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

Correct Answer: D

Rationale: A decreasing WBC count indicates resolving infection, as HAP elevates WBCs. Sputum color is unreliable, lung sounds improve later, and oxygen saturation reflects oxygenation, not infection status.

Question 4 of 5

The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse

Correct Answer: B

Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.

Question 5 of 5

The nurse is reinforcing discharge teaching to several clients with new prescriptions. Which instructions by the nurse about medication administration are correct? Select all that apply.

Correct Answer: A,D

Rationale: Salt substitutes (potassium-based) can cause hyperkalemia with valsartan. Ethambutol can cause optic neuritis, requiring vision change reports. Levofloxacin with antacids reduces absorption. Sucralfate is taken before meals to coat the stomach. Rifampin's red-orange urine is normal, not reportable.

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