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Questions 164

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Question 1 of 5

During the discharge teaching of a client with Buerger's disease, the nurse should teach the client:

Correct Answer: A

Rationale: Exercises to improve vascular return, such as ankle pumps, help manage Buerger's disease by promoting circulation in the extremities.

Question 2 of 5

Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

Correct Answer: C

Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.

Question 3 of 5

A nurse receives report on a group of clients. Which client should the nurse assess first?

Correct Answer: B

Rationale: The toddler with circumoral cyanosis, distress, and inability to speak suggests a potential airway obstruction, a life-threatening emergency requiring immediate assessment. Other clients show less acute symptoms.

Question 4 of 5

The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Elevating the head of the bed (≥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.

Question 5 of 5

The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.

Correct Answer: B,C,D

Rationale: Hirschsprung disease causes intestinal obstruction, leading to a distended abdomen, failure to pass meconium, and nonbilious vomiting. Bright red bleeding suggests other causes (e.g., fissure). Feeding refusal is less specific.

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