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Questions 164

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Question 1 of 5

The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to

Correct Answer: A

Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.

Question 2 of 5

The nurse, assisting in applying a cast to a client with a broken arm, knows that the

Correct Answer: C

Rationale: Wet cast should be handled with the palms of hands. This prevents damage to the cast and ensures proper setting.

Question 3 of 5

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?

Correct Answer: B

Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.

Question 4 of 5

A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?

Correct Answer: A

Rationale: Lethargy. The level of consciousness or responsiveness is the most important measure of the client's rising intracranial pressure, requiring immediate attention.

Question 5 of 5

The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?

Correct Answer: D

Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.

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