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Questions 164

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Question 1 of 5

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?

Correct Answer: D

Rationale: Calf asymmetry of 4 cm suggests deep vein thrombosis, a critical postoperative complication. Pain is nonspecific, negative Homan sign is unreliable, and varicose veins are less urgent.

Question 2 of 5

The nurse is observing a nursing assistant providing care. Which action indicates that the nursing assistant understands universal precautions?

Correct Answer: C

Rationale: Wearing a gown for soiled linen contact adheres to universal precautions, preventing contamination. Limited hand washing, excessive gloves, or no hand washing post-gloves are incorrect.

Question 3 of 5

The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with

Correct Answer: C

Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.

Question 4 of 5

A client with hyperkalemia is to receive an infusion of $250 \mathrm{~mL}$ of $20% glucose with 20 units of regular insulin. The rationale for this therapy is:

Correct Answer: C

Rationale: Insulin facilitates glucose uptake by cells, which drives potassium into cells, lowering serum potassium levels in hyperkalemia.

Question 5 of 5

The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect?

Correct Answer: D

Rationale: Leaving a young child to care for a newborn indicates inadequate supervision, supporting neglect. Job constraints , divorce , and stealing food suggest stress but not direct neglect.

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