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Questions 164

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Extract:


Question 1 of 5

The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?

Correct Answer: A

Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.

Question 2 of 5

The clinic nurse evaluates a client’s response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply.

Correct Answer: A,B,C

Rationale: Levothyroxine corrects hypothyroidism, normalizing heart rate (88/min), improving mood, and increasing energy. Skin should be warm/moist, and weight loss is expected, not gain.

Question 3 of 5

The nurse is administering a tap water enema when the client begins to complain of abdominal cramping. The nurse should:

Correct Answer: B

Rationale: Lowering the enema container slows the flow, reducing cramping. Stopping or withdrawing the tubing is premature, and advancing may worsen discomfort.

Extract:

Exhibit 1
Vital signs

0800
Temperature 98.4 F (36.8 C)
Blood pressure 110/72 mm Hg
Heart rate 52/min
Respirations 16/min

Exhibit 2
Laboratory results

0800
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 40%
(0.4)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L) 14.0 g/dL
(140 g/L)
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 200,000/mm3
(200 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.0 mEq/L
(4.0 mmol/L)


Exhibit 3
Medication administration record

Allergies: No known drug allergies

Medications Time
Aspirin: 81 mg by mouth, daily 0900
Docusate sodium: 100 mg by mouth, daily 0900
Lisinopril: 5 mg by mouth, daily 0900
Metoprolol: 100 mg by mouth, twice daily 0900, 1700
Simvastatin: 20 mg by mouth, daily 2000


Question 4 of 5

A client with ST segment elevation myocardial infarction is due for 0900 medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Aspirin (antiplatelet), lisinopril (ACE inhibitor), metoprolol (beta-blocker), and simvastatin (statin) are standard for STEMI to reduce clot formation, blood pressure, and cholesterol. Docusate is unrelated to STEMI management.

Extract:


Question 5 of 5

A client with schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. A suitable activity for a client with schizophrenia who is experiencing auditory hallucinations is:

Correct Answer: D

Rationale: Taking a walk with the nurse provides distraction and support, reducing focus on hallucinations. Group activities or solitary tasks (B,
C) may be overwhelming or less therapeutic.

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