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Question 1 of 5

The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?

Correct Answer: D

Rationale: Tingling around the mouth after an antibiotic suggests an allergic reaction, potentially anaphylaxis, requiring immediate assessment.

Question 2 of 5

The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified

Question 3 of 5

A client with otosderosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?

Correct Answer: D

Rationale: The seventh cranial (facial) nerve controls facial movements and sensation; changes in facial sensation post-stapedectomy suggest nerve involvement.

Question 4 of 5

The nurse is providing instruction to a client's family regarding home safety with thrombocytopenia. Which statement by the client's family indicates a need for further education?

Correct Answer: D

Rationale: Rugs pose a tripping hazard, increasing bleeding risk in thrombocytopenia. Other statements reflect safe practices to minimize bleeding.

Question 5 of 5

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:

Correct Answer: B

Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.

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A client has been diagnosed with renal insufficiency, which has led to pronounced fluid volume excess. The nurse would expect which of the following signs and symptoms? Select all that apply.
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?
The nurse is preparing to administer a dose of hydralazine (Apresoline) to a client with hypertension. The client’s blood pressure is 90/60 mmHg. Which of the following actions should the nurse take?
Skeletal traction is applied to the right femur of a client injured in a fall. The primary purpose of the skeletal traction is to:

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