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Question 1 of 5

A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

Correct Answer: D

Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.

Question 2 of 5

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

Correct Answer: B

Rationale: Magnesium sulfate toxicity can cause respiratory depression or arrest. Placing an airway at the bedside prepares for potential emergency intervention. The other actions are less specific to managing magnesium toxicity.

Question 3 of 5

A client with a history of chronic lymphocytic leukemia is admitted with complaints of fever. The nurse should give priority to:

Correct Answer: A

Rationale: Fever in chronic lymphocytic leukemia suggests possible infection, a serious complication due to immunosuppression, so monitoring for infection is the priority.

Question 4 of 5

The nurse is teaching a client with hypertension about dietary modifications. Which food choice indicates a need for further teaching?

Correct Answer: C

Rationale: Canned soup is high in sodium, which exacerbates hypertension, indicating a need for further teaching. Apple (
A), chicken (
B), and broccoli (
D) are low-sodium and appropriate.

Question 5 of 5

Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?

Correct Answer: D

Rationale: A low-carbohydrate diet prevents a hypertonic bolus, reducing dumping syndrome. The other options exacerbate the condition.

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A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to:

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