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Questions 149

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Question 1 of 5

An elderly adult has been admitted with a diagnosis of hypertension with a history of dementia. Which of the following nursing diagnoses has the highest priority for this client?

Correct Answer: D

Rationale: Dementia increases fall and injury risk due to impaired judgment and memory, making 'risk for injury' the priority.

Question 2 of 5

A teenage client tells the nurse about her plans to be a lifeguard this summer. The nurse would be concerned if she saw the client was taking which medication? Select all that apply.

Correct Answer: B

Rationale: Isotretinoin (Accutane) causes photosensitivity, increasing sunburn risk, which is concerning for a lifeguard exposed to sunlight. Other medications do not pose significant outdoor risks.

Question 3 of 5

The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?

Correct Answer: C

Rationale:
To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.

Question 4 of 5

The nurse knows that a 60-year-old female client's susceptibility to osteoporosis is most likely related to:

Correct Answer: B

Rationale: Hormonal changes, particularly estrogen loss post-menopause, are the primary cause of osteoporosis in women.

Question 5 of 5

A client with cirrhosis has developed signs of heptorenal syndrome. Which diet is most appropriate for the client at this time?

Correct Answer: C

Rationale: Low protein and low sodium diets reduce the burden on the liver and kidneys in hepatorenal syndrome.

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