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Questions 164

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Extract:


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 is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?

Correct Answer: A

Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.

Question 3 of 5

The nurse is reinforcing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?

Correct Answer: D

Rationale: Polycythemia vera increases blood viscosity, raising the risk of thrombosis. Teaching the client to recognize signs and symptoms of thrombosis, such as swelling or pain in extremities, is critical. Avoiding large crowds relates to infection risk, not thrombosis. Elevating the head of the bed is unrelated, and wearing socks and gloves is more relevant for conditions like Raynaud's.

Question 4 of 5

A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?

Correct Answer: B

Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.

Extract:

Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)


Question 5 of 5

The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?

Correct Answer: B

Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.

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