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Questions 148

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Extract:


Question 1 of 5

The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?

Correct Answer: C

Rationale: Turning the client to one side prevents aspiration, a risk in CVA patients with nausea due to impaired swallowing or consciousness. This is the priority before other actions.

Question 2 of 5

The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?

Correct Answer: D

Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.

Question 3 of 5

The oncoming nurse receives report on a group of clients. Which client should have priority during the nurse's rounds?

Correct Answer: A

Rationale: A client just returning from surgery requires immediate assessment for postoperative complications, making them the priority.

Question 4 of 5

The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?

Correct Answer: A

Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.

Question 5 of 5

The nurse administers 6 units of Humalog (lispro) insulin sub-q to a client at 8:30 a.m. The nurse knows to reassess the client and check for a possible hypoglycemic reaction at

Correct Answer: B

Rationale: Humalog (lispro) is rapid-acting insulin with a peak effect at 1-2 hours. Checking at 9:30 a.m. (1 hour post-administration) aligns with the onset of action to monitor for hypoglycemia.

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