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Questions 149

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Question 1 of 5

A home health nurse finds the client lying unconscious in the doorway of her bathroom. The nurse checks for responsiveness by gently shaking the client and calling her name. When it is determined that the client is nonresponsive, the nurse should:

Correct Answer: C

Rationale: Opening the airway is the first step in managing an unresponsive client to ensure adequate ventilation.

Question 2 of 5

The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?

Correct Answer: C

Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.

Question 3 of 5

A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include:

Correct Answer: B

Rationale: Severe pain from renal calculi can cause increased blood pressure due to sympathetic nervous system activation and stress response.

Question 4 of 5

The nurse is reviewing a new client's medication orders. Which order would prompt the nurse to notify the health care provider?

Correct Answer: C

Rationale: A 50 mg dose of warfarin is unusually high and likely a dosing error, requiring provider clarification. Other orders are within typical ranges.

Question 5 of 5

An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?

Correct Answer: C

Rationale: Lactated Ringer's is isotonic and effective for correcting dehydration in obstetric clients, replacing fluids and electrolytes.

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