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Question 1 of 5

A home care client is scheduled for dialysis. He asks the nurse if he should take his antihypertensive medication before going for dialysis. How should the nurse respond?

Correct Answer: B

Rationale: Antihypertensives are often held before dialysis to prevent hypotension, as dialysis can lower blood pressure. Routine administration, physician checks, or conditional dosing are less appropriate.

Question 2 of 5

The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.

Correct Answer: B,C,D

Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.

Question 3 of 5

The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?

Correct Answer: C

Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.

Question 4 of 5

A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?

Correct Answer: C

Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.

Question 5 of 5

The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene?

Correct Answer: C

Rationale: Raising all side rails during an acute Ménière's episode (vertigo, nausea) increases fall risk if the client attempts to climb over them. Other actions (assisting to commode, dimming lights, turning off TV) reduce stimulation and promote safety.

Similar Questions

The nurse is talking with the parent of a 14-month-old client who was exposed to measles 2 days ago. The client has not received the measles, mumps, and rubella (MMR) vaccine. Which of the following statements would be most appropriate for the nurse to make?
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?
The nurse is caring for an older adult client who has experienced recent multiple falls and weight loss. The client lives with an adult child, but the nurse is questioning the safety of the home. Which of the following interdisciplinary team members would be most appropriate for the nurse to consult?
The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.

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