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Questions 176

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Extract:


Question 1 of 5

The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?

Correct Answer: B

Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.

Question 2 of 5

While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

Correct Answer: B

Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.

Question 3 of 5

Following an arteriogram, the nurse should give priority to:

Correct Answer: D

Rationale: Checking distal pulses ensures adequate circulation post-arteriogram, as the procedure involves arterial puncture, which can lead to complications like hematoma or thrombosis.

Question 4 of 5

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.

Correct Answer: A, B, D

Rationale: Applying to upper arm/chest (
A), folding patches (
B), and rotating sites (
D) ensure safe use. Removing for dizziness (
C) requires medical consultation, and shaving (E) can irritate skin.

Question 5 of 5

An adult is admitted to the emergency department following a fall. A piece of bone is protruding through the skin of the left thigh. In addition to assessing vital signs, what information is most essential to obtain from the client at this time?

Correct Answer: B

Rationale: An open fracture (bone protruding) risks tetanus infection; knowing the last tetanus shot date is critical to determine prophylaxis need. Fall history, environment, or surgeries are secondary.

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