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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 reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?

Correct Answer: A

Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.

Question 3 of 5

A mother brings her two-year-old boy to the pediatrician’s office. Which of the following symptoms would suggest to the nurse that the child has strabismus?

Correct Answer: C

Rationale: visual axes are not parallel so the brain receives two images

Question 4 of 5

The nurse is taking care of an elderly client with congestive heart failure. Which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.

Correct Answer: A, B, D

Rationale: Daily weights monitor fluid status, assistance with self-care reduces exertion, and post-activity vital signs assess heart workload. Sensory stimulation may increase stress.

Question 5 of 5

The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?

Correct Answer: D

Rationale: Grimacing during care indicates pain, prompting the nurse to administer an analgesic.

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