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Question 1 of 5

The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:

Correct Answer: B

Rationale: Continuous observation is needed due to the altered perception caused by hallucinogens, which can lead to unsafe behaviors.

Question 2 of 5

A nurse is triaging in the emergency room when a client enters complaining of muscle cramps and a feeling of exhaustion after a running competition. Which of the following would the nurse suspect?

Correct Answer: B

Rationale: Hyponatremia is common in runners due to excessive water intake or sodium loss through sweat, leading to muscle cramps and exhaustion. Hypernatremia, SIADH, or low potassium would present differently.

Question 3 of 5

The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified

Question 4 of 5

The nurse is caring for a client with suspected endometrial cancer. Which symptom is associated with endometrial cancer?

Correct Answer: D

Rationale: Endometrial cancer often presents with abnormal uterine bleeding, which may manifest as watery or blood-tinged vaginal discharge. Frothy, thick white, or purulent discharges are more indicative of infections or other gynecologic conditions.

Question 5 of 5

A client has been diagnosed with renal insufficiency, which has led to pronounced fluid volume excess. The nurse would expect which of the following signs and symptoms? Select all that apply.

Correct Answer: A,C,E

Rationale: Renal insufficiency causes fluid retention, leading to decreased urine output, jugular vein distention, and tachycardia (compensatory response). Hypotension and weak pulse are more typical of fluid volume deficit.

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