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Questions 164

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Extract:


Question 1 of 5

Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:

Correct Answer: D

Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.

Question 2 of 5

A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?

Correct Answer: C

Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.

Extract:

Vital signs
Temperature 99.2 F (37.3 C)
Blood pressure 134/89 mm Hg
Heart rate 98/min
Respirations 19/min
Oz saturation (SpO) 99%
Sedation Awake, alert


Question 3 of 5

A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive 'another pain pill.' The nurse reviews the medication administration record. Which intervention should the nurse implement?

Correct Answer: A

Rationale: Pain rated 7/10 warrants administration of the prescribed analgesic if within the dosing interval. No indications suggest overdose (naloxone) or need for a different medication. Reducing the dose may inadequately manage pain.

Extract:


Question 4 of 5

A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?

Correct Answer: B

Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.

Question 5 of 5

A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?

Correct Answer: B

Rationale: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.

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