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Questions 164

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Extract:


Question 1 of 5

An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?

Correct Answer: D

Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.

Question 2 of 5

The nurse is reinforcing teaching on self-administering ophthalmic lubricating ointment medication to a client with newly diagnosed Sjogren's syndrome. Which client statement indicates the need for further teaching?

Correct Answer: A

Rationale: Rubbing the eyes after applying ointment (
A) can cause irritation or displace the medication, indicating a need for further teaching. The other statements (B, C,
D) reflect correct administration techniques.

Question 3 of 5

Following cardiac surgery, a client's urine output for the last hour is 20 mL. The nurse understands that this indicates which of the following?

Correct Answer: B

Rationale: Low urine output (20 mL/hour) post-cardiac surgery suggests insufficient cardiac output, impairing renal perfusion. Hyperkalemia, inadequate fluids, or diuresis are less likely causes without additional signs.

Extract:

Laboratory reference ranges
Sodium
136-145 mEq/L
(136-145 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
Creatinine
Male: 0.6–1.3 mg/dL
(53.0–114.9 μmol/L)

Female: 0.5-1.1 mg/dL
(44.2-97.2 μmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)


Question 4 of 5

The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?

Correct Answer: C

Rationale: A potassium level of 7.0 mEq/L (
C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (
A), sodium (
B), and creatinine (
D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.

Extract:


Question 5 of 5

A nurse is collecting data on a 58-year-old client with blurred vision and reduced visual fields. The nurse finds which manifestation most concerning?

Correct Answer: B

Rationale: Extreme eye pain (
B) suggests acute conditions like glaucoma, requiring urgent attention. Difficulty in dim light (
A), peripheral vision loss (
C), and cataracts (
D) are less acute.

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