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Questions 149

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Question 1 of 5

The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:

Correct Answer: D

Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.

Question 2 of 5

Which of the following roommates would be most suitable for the client with myasthenia gravis?

Correct Answer: A

Rationale: Hypothyroidism poses no infection risk, unlike pyelonephritis or bronchitis.

Question 3 of 5

The nurse has just admitted a client with emphysema. Arterial blood gas results indicate hypoxia. Which physician prescription would the nurse implement for the best improvement in the client's hypoxia?

Correct Answer: D

Rationale: Low-flow oxygen (2 L/min) directly addresses hypoxia in emphysema by improving arterial oxygen levels, making it the most effective intervention.

Question 4 of 5

The physician has ordered Amoxil (amoxicillin) 500 mg capsules for a client with esophageal varices. The nurse can best care for the client's needs by:

Correct Answer: D

Rationale: Capsules can be difficult to swallow and may lodge in esophageal varices, increasing the risk of bleeding. An alternate form, such as a liquid, is safer.

Question 5 of 5

A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:

Correct Answer: B

Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.

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