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Questions 158

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Extract:


Question 1 of 5

The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?

Correct Answer: C

Rationale: Edema and neck vein distention in a bronchitis client suggest right heart failure or cor pulmonale, requiring immediate assessment. Emphysema discharge (
A), antibiotics (
B), and abnormal PO2 (
D) are less urgent.

Question 2 of 5

The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:

Correct Answer: B

Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.

Question 3 of 5

The client has an order for Garamycin (gentamicin) to be administered. Which lab test should be done before beginning the medication?

Correct Answer: B

Rationale: Gentamicin, an aminoglycoside, is nephrotoxic. Serum creatinine is monitored before administration to assess baseline kidney function, as impaired renal function increases toxicity risk. Hematocrit, white cell count, and BUN are less specific for gentamicin.

Question 4 of 5

The nurse is caring for a client with a history of sickle cell anemia. Which intervention is most important during a sickle cell crisis?

Correct Answer: A

Rationale: Sickle cell crisis causes vaso-occlusion, reducing tissue oxygenation. Administering oxygen is the priority to prevent hypoxia. Cold packs worsen vasoconstriction, rest is secondary, and antibiotics are for infections.

Question 5 of 5

A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:

Correct Answer: A

Rationale: Adrenalectomy can disrupt cortisol and aldosterone production leading to blood pressure instability (e.g. hypotension from adrenal insufficiency). Monitoring blood pressure is critical to detect and manage these changes promptly.

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