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Question 1 of 5

To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?

Correct Answer: A

Rationale: Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C,
D) The other responses are not expected in this situation and are not even side effects.

Question 2 of 5

The nurse is preparing to collect a sputum specimen from the client suspected of having tuberculosis. What is the correct method for obtaining a sputum specimen?

Question Image

Correct Answer: A, B, C, D

Rationale: Morning collection (
A) yieldsthough sputum is most concentrated. Three consecutive days (
B) ensure reliable tuberculosis diagnosis. Immediate transport (
C) prevents degradation. Mouth care (
D) maintains hygiene. Antiseptic rinse (E) may kill bacteria, invalidating the sample.

Question 3 of 5

The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?

Correct Answer: D

Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.

Question 4 of 5

A client is admitted with symptoms of vertigo and syncope.

Correct Answer: C

Rationale: Left subclavian artery obstruction can cause subclavian steal syndrome, leading to vertigo, syncope, and radial pulse differences (>10 bpm) due to blood flow reversal. Memory loss (
A), numbness (
B), and headache (
D) are unrelated.

Question 5 of 5

A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?

Correct Answer: C

Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.

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A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

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