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Questions 158

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Extract:


Question 1 of 5

The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:

Correct Answer: A

Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.

Question 2 of 5

A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

Correct Answer: A

Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.

Question 3 of 5

Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?

Correct Answer: A

Rationale: Distant breath sounds are characteristic of emphysema due to increased anteroposterior chest diameter, overdistention, and air trapping.

Question 4 of 5

The nurse is caring for a client with a history of a retinal detachment who is scheduled for a scleral buckling procedure. The nurse should:

Correct Answer: B

Rationale: Eye drops (e.g., mydriatics) are often ordered pre-scleral buckling to dilate the pupil or reduce pressure. Flat positioning, fluid restriction, and breathing exercises are not standard.

Question 5 of 5

The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?

Correct Answer: A,C,D,E

Rationale: TLS causes hyperkalemia (
C), hyperuricemia (
D), and mental changes (E) due to electrolyte imbalances and low blood pressure (
A) from fluid shifts. Hyperactivity (
B) is not typical.

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