Extract:

Question 1 of 5

The nurse is caring for a client with a spinal cord injury at C5. Which complication should the nurse monitor for?

Correct Answer: D

Rationale: A C5 spinal cord injury can cause respiratory distress (diaphragm impairment), urinary retention (loss of bladder control), and pressure ulcers (immobility), requiring comprehensive monitoring.

Question 2 of 5

A client has been taking benzonatate as prescribed. The nurse should tell the client this medication performs which action?

A. Increases comfort level B. Decreases anxiety level C. Calms the persistent cough D. Takes away nausea and vomiting

Correct Answer: C

Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. The remaining options are not intended effects of this medication.

Question 3 of 5

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. The nurse should advise the mother to do which of the following?

A. Notify the physician immediately to adjust the treatment plan. B. Confine the infant to one room in the apartment. C. Keep the infant in the splint at night, removing it during the day. D. Remove any unsafe items from the area in which the infant is mobile.

Correct Answer: D

Rationale: Removing unsafe items ensures the infant's safety while mobile in a splint, preventing further injury. The other options are unnecessary or impractical.

Question 4 of 5

The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.

A. Encourage the client to cough and deep breathe. B. Add water to the suction chamber as it evaporates. C. Keep the collection chamber below the client's waist. D. Clamp the chest tube when the client gets out of bed. E. Tape the connection between the chest tube and the drainage system.

Correct Answer: A,B,C,E

Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.

Question 5 of 5

The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?

A. Hearing problems. B. Speech defect. C. Chronic sinus infections. D. Tonsillitis.

Correct Answer: A, B

Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.