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Questions 149

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Question 1 of 5

The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?

Correct Answer: D

Rationale: Asking if the nurse has had chickenpox determines her immunity, as non-immune nurses risk transmitting varicella to an immunocompromised leukemia patient.

Question 2 of 5

The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:

Correct Answer: C

Rationale: In the emergent phase of burns, fluid volume deficit is the priority due to massive fluid loss from damaged skin, risking hypovolemic shock.

Question 3 of 5

The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?

Correct Answer: B

Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.

Question 4 of 5

A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?

Correct Answer: C

Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.

Question 5 of 5

The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:

Correct Answer: D

Rationale: Applying a blood pressure cuff allows monitoring of vital signs during ECT, which is a standard safety measure.

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