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Questions 149

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Question 1 of 5

A nurse is working with an immobile client and doing passive range-of-motion (ROM) exercises on his legs. The client states the exercise is too painful and does not want to continue. The nurse should

Correct Answer: D

Rationale: Pain during ROM exercises may indicate injury. Stopping the exercise prevents harm, with further assessment or pain management to follow.

Question 2 of 5

A client with hyperkalemia is admitted to the telemetry unit. Which of the following would require notification of the health care provider? Select all that apply.

Correct Answer: A, B

Rationale: Spiked T waves and bradycardia (heart rate 53) are signs of severe hyperkalemia, requiring immediate provider notification. Normal heart rate, food refusal, and adequate urinary output (30 cc/hr) are not urgent.

Question 3 of 5

The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

Correct Answer: B

Rationale: Sternal bruises suggest potential chest trauma, requiring priority.

Question 4 of 5

The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?

Correct Answer: C

Rationale: Inserting a Foley catheter allows monitoring of urinary output, which is critical to detect magnesium toxicity, as decreased output is a sign of toxicity.

Question 5 of 5

A client with chronic kidney disease has just been admitted to the floor. The admitting nurse reviews a list of OTC medications the client takes at home and is concerned when he sees

Correct Answer: A

Rationale: Mylanta contains magnesium and aluminum, which can accumulate in kidney disease, causing toxicity. Other medications are less concerning in this context.

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