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Questions 149

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Question 1 of 5

The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?

Correct Answer: C

Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.

Question 2 of 5

The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:

Correct Answer: A

Rationale: Cloudy dialysate indicates possible peritonitis, a serious infection requiring immediate medical intervention to prevent complications.

Question 3 of 5

The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to

Correct Answer: B

Rationale: dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

Question 4 of 5

A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?

Correct Answer: C

Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.

Question 5 of 5

An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication?

Correct Answer: A

Rationale: Crystals in IV fluorouracil indicate precipitation; the solution should be discarded to prevent administration errors.

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