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Questions 148

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Question 1 of 5

The client presents to the emergency room with a hyphema. Which action by the nurse would be best?

Correct Answer: A

Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.

Question 2 of 5

The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following?

Correct Answer: D

Rationale: Lidocaine is the drug of choice for frequent premature ventricular contractions (PV
C) occurring in excess of 6-10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia

Question 3 of 5

A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?

Correct Answer: B

Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.

Question 4 of 5

During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:

Correct Answer: D

Rationale: Covering the client and escorting her to a private area maintains dignity and safety, addressing the inappropriate behavior calmly.

Question 5 of 5

The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse's teaching? Select all that apply.

Correct Answer: A, B, D, E

Rationale: Hepatitis D requires hepatitis B, hepatitis A is year-round and spread via contaminated food/water, and hepatitis B is transmitted through blood/body fluids. Hepatitis D is not waterborne.

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