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Questions 164

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Extract:


Question 1 of 5

The nurse is assisting with the care of a client who sustained a cervical spinal cord injury 1 hour ago and has paralysis in all four extremities. Which of the following actions would be a priority for the nurse to take?

Correct Answer: C

Rationale: Respiratory status (
C) is the priority in acute cervical spinal cord injury due to risk of respiratory failure. Repositioning (
A), dysreflexia monitoring (
B), and exercises (
D) are secondary.

Question 2 of 5

The nurse is caring for a client receiving peritoneal dialysis. Which findings are essential for the nurse to report to the health care provider?

Correct Answer: A,B,E

Rationale: Cloudy outflow (
A), fever (
B), and tachycardia (E) suggest peritonitis, requiring immediate reporting. Oliguria (
C) is expected in renal failure, and pruritus (
D) is less urgent.

Question 3 of 5

The nurse is reinforcing teaching on self-administering ophthalmic lubricating ointment medication to a client with newly diagnosed Sjogren's syndrome. Which client statement indicates the need for further teaching?

Correct Answer: A

Rationale: Rubbing the eyes after applying ointment (
A) can cause irritation or displace the medication, indicating a need for further teaching. The other statements (B, C,
D) reflect correct administration techniques.

Question 4 of 5

Which of the following instructions should be included for the client taking calcium supplements?

Correct Answer: A

Rationale: Taking calcium supplements with meals enhances absorption and reduces gastrointestinal upset.

Question 5 of 5

A client with moderate Alzheimer disease is started on memantine. What should the nurse monitor to evaluate the effectiveness of this medication?

Correct Answer: A

Rationale: Memantine may slow decline and improve daily functioning (
A). It does not stop progression (
B), provide rapid improvement (
C), or reverse Alzheimer's (
D).

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