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Questions 158

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Question 1 of 5

The nurse is caring for a client diagnosed with metastatic cancer of the bone. The client is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?

Correct Answer: B

Rationale: Hypercalcemia (calcium 13 mg/dL) is a common complication of bone metastases, causing confusion and hypertension. Hyperkalemia (
A), low phosphorus (
C), and normal sodium (
D) are less likely causes.

Question 2 of 5

The nurse is caring for a client with a tracheostomy. Which action is a priority to prevent complications?

Correct Answer: A

Rationale: Suctioning as needed prevents airway obstruction from mucus buildup, a priority to maintain patency and prevent respiratory distress. Cuff management, tie changes, and infection monitoring are important but secondary to airway maintenance.

Question 3 of 5

A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:

Correct Answer: C

Rationale: Using Nägele's rule, subtract 3 months and add 7 days from January 15, resulting in October 22.

Question 4 of 5

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Correct Answer: B

Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Question 5 of 5

Which action by the home health nurse indicates a knowledge of the needs of an elderly client?

Correct Answer: D

Rationale: Fall prevention is a critical need for elderly clients due to risks of injury from reduced mobility or balance. Hospice teaching is premature, high-pitched speech may not aid hearing, and fluid restriction can cause dehydration.

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