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Questions 176

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Question 1 of 5

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.

Correct Answer: A, C, E, F

Rationale: Guiding to the floor (
A), clearing objects (
C), positioning laterally (E), and observing (F) ensure safety.
Tongue blades (
B) are dangerous, and restraining (
D) increases injury risk.

Question 2 of 5

The nurse is passing a nasogastric tube into an adult. When passing the tube through the pharynx, the nurse has the client sip water through a straw. What is the purpose of this action?

Correct Answer: C

Rationale: Sipping water during nasogastric tube insertion triggers swallowing, which closes the epiglottis, preventing the tube from entering the trachea and directing it toward the esophagus.

Question 3 of 5

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which of the following additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.

Correct Answer: A, D, E

Rationale: Low blood pressure (
A), tachycardia (
D), and shoulder pain (E) indicate hemorrhage from a ruptured ectopic pregnancy. Crackles (
B) and jugular vein distension (
C) are unrelated.

Question 4 of 5

A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?

Correct Answer: B

Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.

Question 5 of 5

The nurse is caring for a client who has a Clostridioides difficile infection. Which of the following infection control precautions should the nurse implement? Select all that apply.

Correct Answer: B, D

Rationale: A private room (
B) and protective gown (
D) are required for contact precautions. Sterile gloves (
A) are unnecessary, alcohol-based sanitizer (
C) is ineffective against C. difficile spores, and surgical masks (E) are not required.

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