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Questions 227

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Extract:


Question 1 of 5

The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?

Correct Answer: B

Rationale: Increasing oral fluid intake to 3000 cc per day. Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions.

Question 2 of 5

A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:

Correct Answer: B

Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care

Question 3 of 5

The nurse is assessing a client with a suspected fracture of the radius. Which of the following findings would support this diagnosis?

Correct Answer: A

Rationale: A radius fracture typically causes swelling and deformity at the wrist due to bone disruption. Shoulder pain (
B) suggests a proximal injury, leg numbness (
C) is unrelated, and fever/stiffness (
D) indicate infection or arthritis.

Question 4 of 5

The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. The nurse's priority action should be to

Correct Answer: A

Rationale: Terbutaline, a tocolytic, can cause maternal tachycardia. A pulse of 144 indicates significant tachycardia, a side effect requiring the medication to be withheld to prevent further cardiovascular strain. Decreasing the dose (
B) is not within nursing scope, administering (
C) ignores the risk, and waiting (
D) delays intervention.

Extract:

A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.


Question 5 of 5

When obtaining information from the patient, the nurse would expect her to report that:

Correct Answer: D

Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.

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