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Questions 148

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Extract:


Question 1 of 5

The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

Correct Answer: A

Rationale: Applying the new tie before removing the old one ensures the tracheotomy tube remains secure, preventing accidental dislodgement.

Question 2 of 5

Which nurse should be assigned to care for the postpartal client with preeclampsia?

Correct Answer: B

Rationale: The RN with labor and delivery experience is best equipped to manage preeclampsia complications in a postpartal client.

Question 3 of 5

A client with schizophrenia has been taking Clozaril (clozapine) for the past 6 months. This morning the client's temperature was elevated to 102°F. The nurse should give priority to:

Correct Answer: C

Rationale: A fever of 102°F in a client on clozapine may indicate agranulocytosis, a life-threatening side effect, requiring immediate physician notification.

Question 4 of 5

Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?

Correct Answer: C

Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.

Question 5 of 5

A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?

Correct Answer: D

Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (
D). Respiratory imbalances (A,
B) and metabolic acidosis (
C) are less likely.

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