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Questions 149

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Question 1 of 5

The nurse on a physical rehabilitation unit is assigned a 63-year-old male client post-amputation of his left lower limb above the knee two weeks prior. The client has a history of peripheral vascular disease due to diabetes mellitus. Which statement by the client indicates a need for further teaching?

Correct Answer: C

Rationale: Pain after wrapping the stump may indicate improper wrapping or complications, requiring further assessment and education.

Question 2 of 5

After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

Correct Answer: B

Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4

Question 3 of 5

The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:

Correct Answer: A

Rationale: A blood pressure cuff that is too small will result in a false elevation of the blood pressure reading due to increased pressure on the arm.

Question 4 of 5

A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

Correct Answer: A

Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.

Question 5 of 5

Which one of the following situations represents a maturational crisis for the family?

Correct Answer: A

Rationale: A 4-year-old entering nursery school is a maturational crisis, as it involves a normal developmental transition that can stress family dynamics.

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