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Questions 164

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Extract:


Question 1 of 5

The nurse is providing home care to an elderly woman who had a cerebrovascular accident several weeks ago. All of the following need to be done. Which should the nurse plan to do first?

Correct Answer: A

Rationale: Auscultating lung fields assesses respiratory status, a priority post-CVA to detect complications like pneumonia or atelectasis. Hygienic care, ambulation, and ROM are secondary.

Question 2 of 5

Because a client is scheduled for a bronchoscopy tomorrow, the nurse should do which of the following?

Correct Answer: B

Rationale: Bronchoscopy involves sedation and airway manipulation, requiring NPO status after midnight to prevent aspiration, unlike fluids, enemas, or withholding medications.

Question 3 of 5

The nurse in the mental health unit is talking with several clients during group therapy. A client becomes angry and throws a fire extinguisher at another client. Which of the following actions would be a priority for the nurse to take?

Correct Answer: C

Rationale: Ensuring safety by escorting others away (
C) is the priority. Rapid response (
A) may be premature, approaching the client (
B) risks escalation, and informing of consequences (
D) is secondary.

Question 4 of 5

An 8-year old is admitted with drooling, muffled phonation and a temperature of 102.6°. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:

Correct Answer: B

Rationale: Drooling, muffled phonation, and fever suggest epiglottitis, a medical emergency requiring immediate intervention due to the risk of airway obstruction.

Question 5 of 5

The nurse is observing a nursing assistant move a client from bed to chair. Which action by the nursing assistant indicates a lack of understanding about transfer techniques?

Correct Answer: A

Rationale: Bending from the waist risks back injury, indicating improper technique. Wide stance, whole-body turning, and seeking help are correct.

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