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Questions 164

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Question 1 of 5

The nurse enters a client’s room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene?

Correct Answer: D

Rationale: Rolling and folding the stockings creates pressure points, risking skin breakdown and poor circulation. Supine application and correct toe opening placement are appropriate.

Question 2 of 5

The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?

Correct Answer: A

Rationale: The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients.

Question 3 of 5

Damage to the VIII cranial nerve results in:

Correct Answer: B

Rationale: The VIII cranial nerve (vestibulocochlear) is responsible for hearing and balance; damage causes sensorineural hearing loss, affecting the inner ear or nerve pathways.

Question 4 of 5

The client taking a bronchodilator tells the nurse that he is going to begin a smoking cessation program when he is discharged. The nurse should tell the client to notify the doctor if his smoking pattern changes because he will:

Correct Answer: A

Rationale: Changes in smoking patterns should be discussed with the physician because they have an impact on the amount of medication needed. Answer B is incorrect because clients with COPD are placed on expectorants, not antitussives. Answer C is incorrect because an annual influenza vaccine is recommended for all those with lung disease. Answer D is incorrect because benefits from inhaler use should be increased when the client stops smoking.

Question 5 of 5

The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?

Correct Answer: C

Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.

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