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Questions 164

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Question 1 of 5

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Correct Answer: A

Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.

Question 2 of 5

A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?

Correct Answer: B

Rationale: A teacher-coach role is taken by the mentor. A mentor who guides and coaches fosters a productive learning experience.

Question 3 of 5

The nurse is reviewing new orders for a client with chronic kidney disease. The nurse should clarify the order for

Correct Answer: B

Rationale: Magnesium hydroxide risks toxicity in CKD due to impaired excretion. Sodium restriction , fluid restriction , and furosemide are appropriate.

Question 4 of 5

The nurse is talking with a client with major depressive disorder who is receiving isocarboxazid. Which of the following statements by the client would be a priority to follow up?

Correct Answer: A

Rationale: Fatigue may indicate worsening depression or MAOI side effects, requiring urgent follow-up. Constipation and weight gain are common but less critical.

Question 5 of 5

The nurse is observing a staff member perform ear irrigation for an adult client with impacted cerumen. The nurse should intervene if the staff member is observed

Correct Answer: C

Rationale: Pulling the pinna down and back is incorrect for adults; it should be up and back. Slow flow , head tilt , and directing solution upward are correct.

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