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Questions 148

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Question 1 of 5

The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

Correct Answer: B

Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.

Question 2 of 5

The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?

Correct Answer: D

Rationale: Tingling around the mouth after an antibiotic suggests an allergic reaction, potentially anaphylaxis, requiring immediate assessment.

Question 3 of 5

The charge nurse in a cardiac ICU is precepting a student nurse. Which action by the student nurse requires immediate intervention by the charge nurse?

Correct Answer: B

Rationale: Lifting the urinary catheter bag above the bladder risks backflow of urine, increasing infection risk, and requires immediate intervention.

Question 4 of 5

The nurse administers 6 units of Humalog (lispro) insulin sub-q to a client at 8:30 a.m. The nurse knows to reassess the client and check for a possible hypoglycemic reaction at

Correct Answer: B

Rationale: Humalog (lispro) is rapid-acting insulin with a peak effect at 1-2 hours. Checking at 9:30 a.m. (1 hour post-administration) aligns with the onset of action to monitor for hypoglycemia.

Question 5 of 5

When assisting a client with range-of-motion exercises, which movements should be carried out on the client's elbows? Select all that apply.

Correct Answer: A,B,D,E

Rationale: Elbow range-of-motion includes flexion (
B), extension (E), supination (
A), and pronation (
D). Circumduction (
C) is not possible at the elbow, and hyperextension (F) is not a standard motion for this joint.

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