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Questions 149

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Question 1 of 5

The nurse is doing hourly rounds when he finds a 73-year-old female client unconscious on the floor next to the bed. An incident report must be filled out. What is the best statement for the nurse to write on the incident report?

Correct Answer: B

Rationale: The incident report should state objective findings: 'Client was found unresponsive on floor next to the bed.' Speculative statements (slipped, attempted to ambulate) are inappropriate.

Question 2 of 5

The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include:

Correct Answer: D

Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoidance is critical.

Question 3 of 5

A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:

Correct Answer: D

Rationale: Ethambutol can cause optic neuritis, leading to changes in color vision, a serious side effect requiring immediate medical attention.

Question 4 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.

Question 5 of 5

The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?

Correct Answer: C

Rationale: Holding the breath during Davol drain removal prevents air entry into the pleural space, reducing the risk of pneumothorax.

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