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Questions 164

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Extract:


Question 1 of 5

The nurse is administering hygienic care to an elderly client in her home. What should the nurse wash first?

Correct Answer: B

Rationale: Washing the face first during hygienic care respects client comfort and dignity, starting with a less invasive area. It also prevents cross-contamination from dirtier areas like the perineum.

Question 2 of 5

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.

Correct Answer: B,C,E

Rationale: Guiding with an elbow , saying goodbye , and clock-face food arrangement promote safety and orientation. Family input is secondary, and louder/slower speech is unnecessary unless hearing-impaired.

Question 3 of 5

The nurse is preparing to administer scheduled vaccines to a 15-month-old client with Kawasaki disease. The client received IV immunoglobulin 2 months ago. Which of the following vaccines should be delayed? Select all that apply.

Correct Answer: C,E

Rationale: MMR and varicella are live vaccines, which should be delayed 11 months post-IVIG due to antibody interference. Hib , hepatitis B , and pneumococcal are not affected.

Question 4 of 5

The nurse is caring for a 7-year-old client with acute glomerulonephritis. Which of the following is a priority for the nurse to monitor?

Correct Answer: A

Rationale: Hypertension is a priority in glomerulonephritis due to fluid retention, risking complications. Hematuria , edema , and lipids are monitored but less urgent.

Question 5 of 5

The nurse is administering a cleansing enema to a client the night before bowel surgery. When administering the enema, the client reports cramping and pain. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Pausing and slowing the flow reduces cramping by allowing the bowel to adjust. Raising the container increases pressure, reassurance doesn't address pain, and withdrawing the tube is unnecessary.

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