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Questions 164

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Question 1 of 5

The nurse is caring for assigned clients. The nurse should first check the client with

Correct Answer: A

Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.

Question 2 of 5

The nurse is caring for a client who is attempting to leave the hospital against medical advice. The client is competent to make decisions. Which of the following actions would be essential for the nurse to take?

Correct Answer: D

Rationale: Ensuring the provider explains risks ensures informed decision-making, protecting the client and minimizing liability. Medical records are not immediately provided, forms are procedural, and barring future care is incorrect.

Question 3 of 5

The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?

Correct Answer: B

Rationale: Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.

Question 4 of 5

The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma exacerbation? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Severe asthma exacerbations cause accessory muscle use, chest tightness, high-pitched wheezing, and tachypnea due to airway obstruction. Prolonged expiration, not inspiration, is typical as air is trapped.

Question 5 of 5

The nurse is caring for several clients who are to have diagnostic tests. Which clients will receive similar instructions?

Correct Answer: C

Rationale: A barium enema and a colonoscopy both require a clear liquid diet and full bowel prep the day before. The only difference is that the client who is having a barium enema can have red liquids and the one who is having a colonoscopy cannot. The preparation for an upper GI series is NPO after midnight the night before. There is no preparation for a gallbladder sonogram. A gallbladder x-ray requires fat restriction the day before, taking iodine dye tablets, and NPO after midnight. The preparation for a gastroscopy is NPO after midnight the night before.

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