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Questions 164

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Extract:


Question 1 of 5

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A,B,D

Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.

Question 2 of 5

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.

Question 3 of 5

A 4-year old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?

Correct Answer: C

Rationale: A white cell count of 16,000 is elevated, suggesting infection, which must be reported before surgery. Hemoglobin , platelets , and urine specific gravity are normal.

Question 4 of 5

The nurse is talking with the parent of a pediatric client with type 1 diabetes mellitus who has influenza. Which of the following statements by the parent would require follow-up?

Correct Answer: D

Rationale: Decreasing insulin during illness can lead to hyperglycemia or ketoacidosis, as insulin needs may increase.

Question 5 of 5

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

Correct Answer: C

Rationale: If no shock is advised, CPR should resume immediately with chest compressions to restore circulation.

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