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Questions 148

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Extract:


Question 1 of 5

The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should:

Correct Answer: A

Rationale: Securing the IV with tape out of the client's vision minimizes tampering while avoiding restraints or inappropriate actions.

Question 2 of 5

A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

Correct Answer: C

Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.

Question 3 of 5

A 4-year-old male is admitted to the unit with nephrotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:

Correct Answer: B

Rationale: Elevating the scrotum reduces edema by promoting fluid drainage, decreasing discomfort.

Question 4 of 5

The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

Correct Answer: A

Rationale: A tracheotomy set is kept at the bedside post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma.

Question 5 of 5

A nurse needs to draw a blood sample from a patient's central line. The line is currently infusing Ringer's lactate. In which order should the nurse take the following steps to draw the blood sample? Number the steps below.

Order the Items

Source Container

attach the flush syringe and flush catheter with normal saline
stop the infusion and disconnect Ringer's lactate
withdraw a blood sample and discard
scrub the catheter hub
withdraw the blood sample for the lab

Correct Answer: B,D,C,A,E

Rationale: Order: Stop infusion (
B), scrub hub (
D), withdraw/discard blood (
C), flush with saline (
A), withdraw lab sample (E). This ensures a clean, accurate sample.

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