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Questions 164

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Extract:

Vital signs
Temperature 98.7 F (37.05 C)
Blood pressure 110/64 mm Hg
Heart rate 92/min
Respirations 22/min
O2 saturation or SpO2 90% on room air


Question 1 of 5

An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?

Correct Answer: A

Rationale: Observing the client (
A) allows assessment of the behavior's cause. Assuming dissatisfaction (
B) or dementia (
D) is premature. Leaving the client (
C) delays intervention.

Extract:


Question 2 of 5

A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, 'What would you do if this was your family member?' How should the nurse respond?

Correct Answer: C

Rationale: Exploring pros and cons (
C) empowers the MPOA to make an informed decision. Personal opinions (
A), chaplain referral (
B), or family meetings (
D) are less direct.

Question 3 of 5

When reviewing the chart of a client with long standing lung disease, the nurse should pay close attention to the results of which pulmonary function test?

Correct Answer: C

Rationale: The FEV1/FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answers A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.

Question 4 of 5

An 8-year old is admitted with drooling, muffled phonation and a temperature of 102.6°. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:

Correct Answer: B

Rationale: Drooling, muffled phonation, and fever suggest epiglottitis, a medical emergency requiring immediate intervention due to the risk of airway obstruction.

Question 5 of 5

The nurse is caring for a client with heart failure who develops a persistent, dry cough after starting enalapril. Which of the following new prescriptions would the nurse anticipate for this client?

Correct Answer: D

Rationale: A dry cough is a common side effect of ACE inhibitors like enalapril, so switching to an ARB like valsartan (
D) is anticipated. Alprazolam (
A), guaifenesin (
B), and lisinopril (C, another ACE inhibitor) are inappropriate.

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