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Questions 149

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Question 1 of 5

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:

Correct Answer: B

Rationale: Dressing in extra layers of clothing is a safe and effective way to manage cold intolerance in hypothyroidism, avoiding risks associated with electric blankets or heating pads.

Question 2 of 5

The nurse is auscultating a client's breath sounds. Low-pitched grating and rubbing are noted on inhalation and exhalation. What will the nurse chart under assessment findings?

Correct Answer: C

Rationale: Low-pitched grating/rubbing sounds indicate a pleural friction rub, often due to pleural inflammation.

Question 3 of 5

The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation, increasing the risk of urinary retention, so hourly voiding is encouraged.

Question 4 of 5

The nurse is preparing to administer heparin to a client with a deep vein thrombosis. Which of the following laboratory values should the nurse check before administering the dose?

Correct Answer: B

Rationale: heparin’s therapeutic effect is monitored by aPTT, which should be 1.5–2 times the control value

Question 5 of 5

While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:

Correct Answer: A

Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.

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