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Questions 158

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Question 1 of 5

The nurse is caring for a client with a history of Sjögren’s syndrome. The nurse should expect the client to have:

Correct Answer: A

Rationale: Sjögren’s syndrome is an autoimmune condition causing reduced salivary and lacrimal gland function, leading to dry eyes and mouth.

Question 2 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation leading to urinary retention. Hourly catheterization prevents bladder distention and complications. The other reasons are not accurate or relevant to epidural effects.

Question 3 of 5

The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

Correct Answer: C

Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (
A), wheezing (
B), and pain/rales (
D) are concerning but less urgent.

Question 4 of 5

The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:

Correct Answer: A

Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.

Question 5 of 5

A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

Correct Answer: C

Rationale: Auscultating fetal heart rate is critical after membrane rupture to assess for cord prolapse, a potential complication.

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