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Question 1 of 5

The nurse is caring for a client with suspected tracheoesophageal fistula and esophageal atresia. The nurse is most likely to observe

Correct Answer: A

Rationale: Tracheoesophageal fistula and esophageal atresia prevent normal swallowing, leading to pooling of saliva and excessive salivation. Abdominal distension or vomiting may occur in some cases, but salivation is the most consistent sign. Diminished lung sounds are less specific.

Question 2 of 5

When performing an assessment on the client with emphysema, the nurse finds that the client has a barrel chest. The alteration in the client's chest is due to:

Correct Answer: B

Rationale: Clients with emphysema develop a barrel chest due to the trapping of air in the lungs, causing them to hyperinflate. Answers C and D are common in those with emphysema but do not cause the chest to become barrel shaped. Answer A does not occur in emphysema.

Question 3 of 5

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

Correct Answer: B

Rationale: The neck veins should be assessed for distension in the client with congestive heart failure. Edema of the feet and hands does not indicate central circulatory overload, so answers A and C are incorrect. Edema of the sacrum is an indication of right-sided congestive heart failure, so answer D is incorrect.

Question 4 of 5

A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in an incubator. Which action is a nursing priority?

Correct Answer: B

Rationale: Monitor the neonate's temperature. When using a warming device the neonate's temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.

Question 5 of 5

A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?

Correct Answer: A

Rationale: Denial, per Kübler-Ross's

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