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Questions 149

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Question 1 of 5

A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?

Correct Answer: A

Rationale: Increased jaundice and prolonged prothrombin time indicate liver dysfunction, consistent with acute liver transplant rejection.

Question 2 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment

Question 3 of 5

The nurse is caring for a client with bulimia nervosa. The nurse recognizes that the major difference in the client with anorexia nervosa and the client with bulimia nervosa is the client with bulimia:

Correct Answer: C

Rationale: Clients with bulimia often recognize their eating disorder, unlike those with anorexia, who may deny the problem due to distorted body image.

Question 4 of 5

If a nurse accidentally punctures a finger with a needle after withdrawing blood from a client, which of the following actions should be carried out first?

Correct Answer: B

Rationale: Washing the puncture with soap and water (
B) is the first step to reduce infection risk. Other actions (A, C,
D) follow.

Question 5 of 5

The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

Correct Answer: A

Rationale: The tape test, applied to the perianal area at night or early morning, is the standard method to collect pinworm eggs.

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