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Questions 149

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Extract:


Question 1 of 5

The home health nurse is visiting an elderly client following a hip replacement. Which finding requires further teaching?

Correct Answer: C

Rationale: A soft, low sofa can make it difficult for a client with a hip replacement to stand up safely, increasing the risk of falls or injury.

Question 2 of 5

A 4-year-old is admitted to the hospital for treatment of Kawasaki's disease. The medication commonly prescribed for the treatment of Kawasaki's disease is:

Correct Answer: A

Rationale: Aspirin is used in Kawasaki's disease to reduce inflammation and prevent coronary artery complications, often with intravenous immunoglobulin.

Question 3 of 5

The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:

Correct Answer: D

Rationale: Checking the site for bleeding ensures early detection of hematoma or excessive bleeding post-heparin injection.

Question 4 of 5

A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse that they observed the client's head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations 22. Which is the client's most appropriate priority nursing diagnosis?

Correct Answer: B

Rationale: Hypotension (BP 70/34) and tachycardia (HR 130) indicate hypovolemic shock, likely from blood loss. Fluid volume deficit is the priority diagnosis to address life-threatening hypovolemia.

Question 5 of 5

The nurse is caring for a client following a transphenoidal hypophysectomy. Post-operatively, the nurse should:

Correct Answer: B

Rationale: The halo sign on the nasal dressing indicates cerebrospinal fluid leakage, a critical post-operative complication.

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