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Questions 164

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Extract:


Question 1 of 5

A nurse is collecting data on a 58-year-old client with blurred vision and reduced visual fields. The nurse finds which manifestation most concerning?

Correct Answer: B

Rationale: Extreme eye pain (
B) suggests acute conditions like glaucoma, requiring urgent attention. Difficulty in dim light (
A), peripheral vision loss (
C), and cataracts (
D) are less acute.

Question 2 of 5

Prior to administering a feeding, the nurse checks for placement of a feeding tube. What is the best way to do this?

Correct Answer: B

Rationale: Measuring the pH of aspirated fluid (pH <5.5) confirms gastric placement, the most reliable method to prevent aspiration.

Extract:

Vital signs
Blood pressure 105/60 mm Hg
Heart rate 80/min
Respirations 22/min
SpO2 90% on room air
Nurse notes
The client has a history of coronary artery disease and peripheral vascular disease. Nursing assessment reveals crackles in middle & lower lung fields, moderate jugular venous distension, and 3+ pedal edema.
Medications
Enoxaparin: 30 mg subcutaneous once daily
Metoprolol: 50 mg PO twice a day
Furosemide: 40 mg PO twice daily
Atorvastatin: 20 mg PO once daily


Question 3 of 5

The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?

Correct Answer: D

Rationale: Metoprolol (
D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (
C) treats fluid overload, enoxaparin (
B) prevents thrombosis, and atorvastatin (
A) manages lipids.

Extract:


Question 4 of 5

The nurse receives the handoff of care report on four clients. Which client should the nurse see first?

Correct Answer: D

Rationale: Restlessness in a pneumonia client with low SpO2 (
D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (
A) is urgent but stable. Pleural effusion (
B) and fever (
C) are less critical.

Question 5 of 5

The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?

Correct Answer: A

Rationale: Lumbar punctures are typically performed in a lateral or sitting position, not prone (
A), requiring clarification. Urinating beforehand (
B), needle insertion (
C), and transient pain (
D) are correct.

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