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Questions 148

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Extract:


Question 1 of 5

The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?

Correct Answer: A

Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.

Question 2 of 5

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

Correct Answer: D

Rationale: A bus trip to a museum is a low-exertion activity at sea level, minimizing the risk of hypoxia compared to high-altitude or strenuous activities.

Question 3 of 5

A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.

Correct Answer: A,B,E

Rationale: Phenytoin's long-term effects include gingival hypertrophy (
A), hirsutism (
B), and anemia (E). Facial hypertrophy (
C) and dementia (
D) are not associated with phenytoin.

Question 4 of 5

The nurse is assessing a client with suspected Addison’s disease. Which of the following findings would the nurse expect?

Correct Answer: B

Rationale: hyperpigmentation of the skin is a classic sign of Addison’s disease due to increased ACTH production

Question 5 of 5

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

Correct Answer: A

Rationale: Clients with MRSA require contact precautions due to the highly contagious nature of the infection, necessitating a private room to prevent transmission to others.

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