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Questions 163

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Extract:


Question 1 of 5

The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?

Correct Answer: B

Rationale: Assessing breath sounds is the first step to evaluate the extent of fluid overload and guide interventions in heart failure. Oxygen , monitoring , and IV insertion follow based on findings.

Extract:

Laboratory Reference Ranges
Glucose – Fasting

70–110 mg/dL
(3.9–6.1 mmol/L)


Question 2 of 5

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM fasting blood glucose is 60 mg/dL. Which action should the nurse recommend to the client?

Correct Answer: B

Rationale: A fasting blood glucose of 60 mg/dL indicates hypoglycemia risk with NPH insulin, which peaks overnight. A bedtime snack prevents nocturnal hypoglycemia. Ketones are checked for hyperglycemia, increased carbohydrates may cause hyperglycemia, and skipping doses disrupts control.

Extract:


Question 3 of 5

The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

Correct Answer: D

Rationale: Left sided heart failure exhibits signs of pulmonary compromise (SO
B).

Question 4 of 5

The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?

Correct Answer: D

Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.

Question 5 of 5

Which statement, if made by the client, indicates a possible problem?

Correct Answer: B

Rationale: Black stools may indicate gastrointestinal bleeding, a serious concern requiring evaluation. Other statements reflect normal variations or minor issues.

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