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Questions 149

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Question 1 of 5

The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

Correct Answer: C

Rationale: Identifying peripheral pulses is critical to assess baseline circulation, as an abdominal aortic aneurysm can affect distal blood flow.

Question 2 of 5

The nurse is assisting in the care of a client with diverticulosis. Which of the following assessment findings must necessitate an immediate report to the doctor?

Correct Answer: D

Rationale: Low hemoglobin (26%) and hematocrit (32) suggest significant bleeding, requiring immediate reporting for further evaluation.

Question 3 of 5

A nurse is preparing to administer a MMR vaccine to a 35-year-old male. The nurse should

Correct Answer: D

Rationale: MMR is an intramuscular vaccine, requiring a 90-degree angle injection (typically deltoid). Dorsogluteal is not preferred, and pinching is for subcutaneous injections.

Question 4 of 5

The nurse is discharging a client with a prescription of eyedrops. Which observation by the nurse would indicate a need for further client teaching?

Correct Answer: B

Rationale: Administering a second eyedrop immediately washes out the first. A 5-minute wait is needed, indicating a need for further teaching.

Question 5 of 5

A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?

Correct Answer: C

Rationale: IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action

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