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Questions 148

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Question 1 of 5

The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

Correct Answer: C

Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.

Question 2 of 5

The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?

Correct Answer: D

Rationale: Disequilibrium syndrome can occur during hemodialysis due to rapid shifts in fluids and electrolytes, causing symptoms like anxiety, tachypnea, and hypotension.

Question 3 of 5

A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.

Correct Answer: A,B,C,F

Rationale: Bowel training includes scheduled toileting (
A), stool softeners (
B), high-fiber diet (
C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (
D) and periodic enemas (E) are not preferred long-term.

Question 4 of 5

Which statement by the client regarding sickle cell disease indicates a need for further teaching?

Correct Answer: B

Rationale: Alcohol, including red wine, can cause dehydration and increase the risk of sickle cell crisis, so it should be avoided. Other statements are correct.

Question 5 of 5

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

Correct Answer: B

Rationale: Tachypnea (respirations 28 shallow) is a common sign of anemia due to reduced oxygen-carrying capacity, prompting compensatory increased respiratory rate.

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