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Questions 210

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Extract:


Question 1 of 5

The client screams at the nurse, 'You are all incompetent here! I have been waiting for 2 hours!' How should the nurse respond initially?

Correct Answer: C

Rationale: Acknowledging the client's frustration and offering assistance de-escalates the situation and focuses on solutions. Threatening security escalates tension, and the other options dismiss the client's feelings or fail to address the issue.

Question 2 of 5

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?

Correct Answer: C

Rationale: Preparing intubation and suction supplies ensures readiness for airway protection, as gastric lavage carries a risk of aspiration. Small-bore tubes are inadequate for lavage, Trendelenburg increases aspiration risk, and waiting an hour delays urgent treatment.

Question 3 of 5

The nurse is caring for a woman who has diabetic neuropathy. The nurse knows that the client needs more instruction when the client makes which statement?

Correct Answer: A

Rationale: Hot water bottles can burn insensitive neuropathic feet, risking injury. Drying feet, podiatrist care, and using Tegretol for neuropathic pain are appropriate.

Extract:

Exhibit 1
Assessment data
0600 Wednesday 0600 Thursday
Blood pressure 148/84 mm Hg 98/60 mm Hg
24-hour intake/output 1000/3000 mL ---------------
Exhibit 2
Laboratory results
0600 Wednesday 0600 Thursday
Sodium
136-145 mEq/L
(136-145 mmol/L) 140 mEq/L
(140 mmol/L) 150 mEq/L
(150 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.2 mEq/L
(4.2 mmol/L) 3.5 mEq/L
(3.5 mmol/L)
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L) 90 mg/dL
(5 mmol/L) 99 mg/dL
(5.5 mmol/L)

Exhibit 3
Medication administration record
Allergies: None
Medications Thursday
Furosemide: 40 mg IVP, once daily 0700
Levofloxacin: 500 mg IV, once daily 0700
Glipizide: 5 mg orally, twice daily 0700-1700
Potassium chloride: 20 mEq/L orally, once daily 0700


Question 4 of 5

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering?

Correct Answer: A

Rationale: Furosemide in heart failure requires careful monitoring of fluid status and electrolytes, especially early in the day, to avoid exacerbating dehydration or hypotension. Glipizide, levofloxacin, and potassium chloride are appropriate for diabetes, UTI, and potential hypokalemia, respectively.

Extract:


Question 5 of 5

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply.

Correct Answer: A,B,D

Rationale: Moisture barrier cream protects skin, cleaning after incontinence prevents irritation, and foam cushions reduce pressure. Massaging bony prominences can cause tissue damage, and repositioning every 6 hours is too infrequent; every 2 hours is standard.

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