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Questions 149

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Question 1 of 5

The nurse is caring for a 12-year-old client with appendicitis. The client's mother is a Jehovah's Witness and refuses to sign the blood permit. What nursing action is most appropriate?

Correct Answer: D

Rationale: Notifying the physician respects the mother's beliefs while ensuring the medical team addresses the refusal appropriately.

Question 2 of 5

The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?

Correct Answer: C

Rationale: Alendronate should be taken with water only to ensure proper absorption and minimize esophageal irritation.

Question 3 of 5

The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?

Correct Answer: C

Rationale: Inserting a Foley catheter allows monitoring of urinary output, which is critical to detect magnesium toxicity, as decreased output is a sign of toxicity.

Question 4 of 5

The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, bicarb 28. The nurse would assess the client to be in:

Correct Answer: C

Rationale: Normal pH with elevated CO2 and bicarbonate indicates compensated respiratory acidosis, typical in COPD.

Question 5 of 5

A client who has just undergone a laparoscopic cholecystectomy complains of 'free air pain.' What would be your best action?

Correct Answer: A

Rationale: Free air pain' after laparoscopic cholecystectomy is due to residual carbon dioxide in the abdomen. Ambulation helps disperse the gas and relieve pain.

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