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Questions 148

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Question 1 of 5

The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?

Correct Answer: A

Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.

Question 2 of 5

According to the American Heart Association (2005) guidelines the compression-to-ventilation ratio for one rescuer cardiopulmonary resuscitation is:

Correct Answer: C

Rationale: The 2005 AHA guidelines specify a 30:2 compression-to-ventilation ratio for one-rescuer CPR in adults.

Question 3 of 5

The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?

Correct Answer: D

Rationale: Tingling around the mouth after an antibiotic suggests an allergic reaction, potentially anaphylaxis, requiring immediate assessment.

Question 4 of 5

The nurse is assessing a client with suspected pneumothorax. Which of the following findings would the nurse expect?

Correct Answer: B

Rationale: decreased breath sounds on the affected side are a hallmark of pneumothorax due to lung collapse

Question 5 of 5

Upon admission to the hospital, a client reports having 'the worst headache I've ever had.' The nurse should give the highest priority to:

Correct Answer: C

Rationale: A sudden, severe headache may indicate a serious condition like subarachnoid hemorrhage. Neuro checks are the priority to assess for neurological changes.

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