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Questions 148

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Question 1 of 5

The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?

Correct Answer: B

Rationale: A torque wrench is needed to adjust and maintain the tension of crutchfield tongs for cervical stabilization.

Question 2 of 5

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

Correct Answer: B

Rationale: Tachypnea (respirations 28 shallow) is a common sign of anemia due to reduced oxygen-carrying capacity, prompting compensatory increased respiratory rate.

Question 3 of 5

The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?

Correct Answer: B

Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority

Question 4 of 5

A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Correct Answer: C

Rationale: Diet history is less directly related to diagnosing a bowel obstruction compared to pain, vomiting characteristics, or abdominal distension, which are hallmark symptoms.

Question 5 of 5

An infant with a ventricular septal defect is discharged with a prescription for lanoxin elixir 0.01 mg PO q 12 hrs. The bottle is labeled 0.10 mg per 1/2 tsp. The nurse should instruct the mother to:

Correct Answer: B

Rationale: The calibrated dropper ensures accurate dosing of Lanoxin (digoxin), critical for preventing toxicity in infants.

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