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Questions 149

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Question 1 of 5

The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:

Correct Answer: D

Rationale: Oliguria may indicate diabetes insipidus, a common complication after pituitary surgery due to antidiuretic hormone deficiency.

Question 2 of 5

The nurse arrives at a motorcycle accident and finds the client unresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse's next action?

Correct Answer: B

Rationale: Per ACLS guidelines, for an unresponsive, apneic, pulseless client, start chest compressions immediately after calling for help to restore circulation.

Question 3 of 5

The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother?

Correct Answer: D

Rationale: Placing the baby in bed awake after a late feeding promotes self-soothing and healthy sleep habits, unlike the other options, which may create dependencies or safety risks.

Question 4 of 5

The physician has prescribed a Becloforte (beclomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:

Correct Answer: B

Rationale: A sore throat may indicate oral candidiasis, a side effect of inhaled corticosteroids like beclomethasone.

Question 5 of 5

The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last

Order the Items

Source Container

Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
Apply the irrigation sleeve over the stoma.
Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.

Correct Answer: E,D,C,B,A

Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.

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