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Questions 227

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Extract:

Six hours following bilateral hip replacement, an 80-year-old woman, transferred in from the Recovery Room to the Surgical Unit was observed to be confused and lethargic; VS are BP 82/56; HR 120; RR 28; skin cool and clammy; no c/o SOB; lungs sounds clear; u/o 20 ml/hour; T 36.5°C; WBC 9000.


Question 1 of 5

Based on this information, what condition appears to be developing?

Correct Answer: D

Rationale: Low blood pressure, tachycardia, and low urine output suggest hypovolemic shock, likely from postoperative bleeding.

Extract:


Question 2 of 5

The nurse has been assigned to four clients in the emergency room, each experiencing one of these conditions. Which client condition would the nurse check first?

Correct Answer: C

Rationale: Tension pneumothorax with slight tracheal deviation to the right. Tracheal deviation indicates a life-threatening condition with risk of cardiac tamponade.

Extract:

During examination of a 36-year-old woman's right breast, you palpate a lump.


Question 3 of 5

Which characteristic most suggests that the lump may be malignant?

Correct Answer: B

Rationale: Irregular shape is a concerning feature of malignant breast lumps.

Extract:


Question 4 of 5

Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)?

Correct Answer: C

Rationale: Chocolate relaxes the lower esophageal sphincter, worsening GERD symptoms. The other foods are less likely to trigger reflux. Basic Care and Comfort

Question 5 of 5

Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?

Correct Answer: C

Rationale: Severe burns (50% of the body) significantly increase the risk of infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling (
A) and peer visits (
D) address psychosocial needs, which are secondary, and airborne precautions (
B) are unnecessary (standard precautions suffice).

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