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Questions 149

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Question 1 of 5

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

Correct Answer: C

Rationale: Pinching the soft lower part of the nose is the most effective way to control a nosebleed in a client with hemophilia, as it applies direct pressure to the bleeding site.

Question 2 of 5

The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse's initial action should be to:

Correct Answer: B

Rationale: Increasing normal saline infusion addresses hypovolemic shock, likely due to post-thyroidectomy hemorrhage, as the priority action.

Question 3 of 5

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Correct Answer: C

Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.

Question 4 of 5

Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?

Correct Answer: A

Rationale: Chemotherapy suppresses the immune system, increasing the risk of opportunistic infections like pneumocystis pneumonia.

Question 5 of 5

A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:

Correct Answer: C

Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.

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