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Questions 164

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Question 1 of 5

The 11:00 AM routine fingerstick (glucose monitoring) test for a client was assigned to the unlicensed assistive personnel by the nurse. At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first?

Correct Answer: C

Rationale: Performing the test ensures timely glucose monitoring, which is critical for the client's care.

Question 2 of 5

The nurse is talking with a client with acne vulgaris who has a new prescription for isotretinoin. Which of the following statements by the client would require follow-up?

Correct Answer: C

Rationale: Vitamin A supplements can increase the risk of toxicity with isotretinoin, which is a vitamin A derivative.

Question 3 of 5

The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?

Correct Answer: A

Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.

Question 4 of 5

The nurse is observing the movements of a client receiving Thorazine (chlorpromazine). The client continually paces and rocks back and forth when sitting. The nurse recognizes that the client is experiencing:

Correct Answer: B

Rationale: Akathisia is characterized by restlessness, pacing, and rocking, which matches the client's symptoms. Answer A involves fixed upward gaze, Answer C involves muscle spasms, and Answer D involves slowed movements, all of which are incorrect.

Question 5 of 5

The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.

Correct Answer: A,D,E

Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.

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