Questions 150

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Question 1 of 5

During your system specific assessment of your client's peripheral pulses, you note that the client's posterior tibia pulse is weak and thready. You would document this finding as:

Correct Answer: C

Rationale: A weak and thready pulse is documented as 1+ on a 0-4+ scale, indicating diminished pulse strength.

Question 2 of 5

Which of the following assessment finding is expected in a client with bacterial pneumonia?

Correct Answer: A

Rationale: Increased fremitus is expected in bacterial pneumonia due to lung consolidation.

Question 3 of 5

A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects immediately?

Correct Answer: C

Rationale: A rash may indicate a serious hypersensitivity reaction to phenytoin, such as Stevens-Johnson syndrome, requiring immediate reporting.

Question 4 of 5

The nurse is caring for a client who has just received a diagnosis of terminal cancer. The client says, 'I don't want to tell my family yet.' Which of the following responses by the nurse is most appropriate?

Correct Answer: B

Rationale: Respecting the client's autonomy while offering support is the most appropriate response, honoring their decision about disclosure.

Question 5 of 5

A client is ready to be discharged from same-day surgery following an inguinal hernia repair. Which criteria must the client meet before the nurse can discharge the client?

Correct Answer: C

Rationale: The ability to walk to the bathroom indicates sufficient recovery of mobility and stability, a key discharge criterion. Pain control and urination are also important, but mobility is critical.

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