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Questions 163

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Question 1 of 5

The nurse is auscultating the lungs in a postoperative client and hears something that sounds like a cellophane bag being wrinkled when the client takes in a breath. How should the nurse record this finding?

Correct Answer: A

Rationale: Crackles, sounding like crinkling cellophane, indicate fluid in alveoli or airway collapse, common post-surgery. Stridor, stertor, and wheezes have different characteristics.

Question 2 of 5

The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin?

Correct Answer: C

Rationale: Vancomycin and gentamicin are nephrotoxic, so monitoring for increased serum creatinine is essential to detect kidney injury. GI bleeding , anemia , and muscle cramps are less directly related.

Question 3 of 5

While sitting at the nurse's station, the nurse observes that a client uses a tissue to pick up magazines and change channels on the television. There has been no such behavior in the past. The nurse should:

Correct Answer: A

Rationale: Talking with the client assesses potential obsessive-compulsive behavior or anxiety. Gloves or removing tissues may escalate distress. Attention-seeking is an assumption without evidence.

Question 4 of 5

The nurse is caring for a client who is in the first stage of labor and is reporting intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: For back pain in labor with a right occiput posterior position, applying counterpressure to the sacrum relieves discomfort. Supine position worsens pain, bed rest limits mobility, and epidural is not the first intervention.

Question 5 of 5

The nurse is reviewing new medication prescriptions for a client with asthma and nasal polyps. The nurse should clarify the prescription for

Correct Answer: A

Rationale: Ibuprofen should be clarified in asthma with nasal polyps due to risk of aspirin-exacerbated respiratory disease. Vitamin D , albuterol , and montelukast are safe.

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