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Questions 164

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Question 1 of 5

An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

Correct Answer: B

Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.

Question 2 of 5

The charge nurse observes a student nurse administering a tuberculin skin test using the intradermal route. Which action by the student nurse requires intervention and additional teaching from the charge nurse?

Correct Answer: A

Rationale: Advancing until the bevel is invisible (
A) is too deep for intradermal injection, requiring intervention. Syringe choice (
B), wheal formation (
C), and angle (
D) are correct.

Question 3 of 5

A 78-year-old client is admitted following a cerebrovascular accident. He cannot move his left arm and leg. Which finding would indicate to the nurse that the client also has homonymous hemianopia?

Correct Answer: B

Rationale: Homonymous hemianopia, a visual field defect from right brain stroke, causes left-sided vision loss, so the client misses the nurse on the left, unlike arm movement, swallowing, or speech issues.

Question 4 of 5

The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?

Correct Answer: B

Rationale: Eating 30 minutes after NPH and regular insulin (
B) risks hypoglycemia, as regular insulin acts within 30 minutes. Checking glucose (
A), using new syringes (
C), and sliding scale for regular insulin (
D) are correct.

Question 5 of 5

The nurse is caring for a woman who has internal radiation for cancer of the cervix. Which of the following situations poses the greatest risk for others?

Correct Answer: A

Rationale: Prolonged close contact (daughter's hours-long visit) increases radiation exposure risk. Brief visits, tray setup, or mopping pose minimal risk.

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