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Questions 164

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Extract:


Question 1 of 5

A nurse receives report on a group of clients. Which client should the nurse assess first?

Correct Answer: B

Rationale: The toddler with circumoral cyanosis, distress, and inability to speak suggests a potential airway obstruction, a life-threatening emergency requiring immediate assessment. Other clients show less acute symptoms.

Question 2 of 5

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?

Correct Answer: C

Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.

Question 3 of 5

The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel?

Correct Answer: A

Rationale: Checking blood glucose and reporting results is within UAP scope if trained. Teaching, monitoring for hypoglycemia, and updating care plans require nursing judgment and are outside UAP scope.

Question 4 of 5

A client with myxedema should be prescribed which diet?

Correct Answer: B

Rationale: Myxedema (hypothyroidism) slows metabolism, so a high-carbohydrate diet provides energy to support metabolic needs.

Question 5 of 5

Which of the following instructions should be given to a client regarding testicular self-exam?

Correct Answer: B

Rationale: Testicular self-examination (TSE) is recommended monthly, not bimonthly or yearly, and is best performed during or after a warm shower or bath when the scrotum is relaxed, making it easier to detect abnormalities. Transillumination is a medical procedure, not part of TSE.

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