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Questions 164

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Question 1 of 5

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial post-procedure monitoring plan should include what? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Monitoring alertness, lung sounds, oxygen saturation, and respiratory pattern detects complications like pneumothorax or respiratory distress.

Question 2 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.

Question 3 of 5

The nurse is observing client care situations. Which of the following situations would require an order for physical restraints? Select all that apply.

Correct Answer: D,E

Rationale: Belt and ankle restraints require a provider's order due to their restrictive nature. Immobilizers, mummy restraints, and padded rails are typically used for specific purposes without restraint orders.

Question 4 of 5

The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider?

Correct Answer: A

Rationale: Fever in Kawasaki disease may indicate persistent inflammation or complications, requiring immediate reporting.

Question 5 of 5

A client with a history of renal calculi passes a stone made up of calcium oxalate. Which of the following diet instructions should be given to the client?

Correct Answer: C

Rationale: Dark green, leafy vegetables are high in oxalates, which contribute to calcium oxalate stones. Meats and dairy increase other stone types, and citrus juices are beneficial.

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