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Questions 149

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Question 1 of 5

An elderly preoperative client seems very anxious but denies concerns when the nurse asks; however, the client's son confides that the client is very superstitious and believes it is bad luck that he is in room 113. Which of the following actions is the best response?

Correct Answer: B

Rationale: Reassigning the client to a different room (
B) addresses the client's anxiety by respecting his superstitious beliefs, promoting comfort. Reassurance (
A), medication (
C), or family presence (
D) may not fully alleviate the specific concern.

Question 2 of 5

The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:

Correct Answer: C

Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.

Question 3 of 5

The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?

Correct Answer: D

Rationale: Deflating the cuff during meals allows normal swallowing, reducing aspiration risk, and is maintained for 1 hour post-meal.

Question 4 of 5

A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?

Correct Answer: C

Rationale: Pernicious anemia causes B12 deficiency, leading to neurological symptoms like paresthesia. Noncompliance with B12 injections would result in persistent or worsening paresthesia.

Question 5 of 5

The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?

Correct Answer: A

Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns

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