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Questions 164

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Question 1 of 5

When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?

Correct Answer: A

Rationale: Risk for injury: hemorrhage. Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. Hemorrhage, especially from esophageal varices, can be life-threatening.

Question 2 of 5

The nurse is new to the resident facility and is administering medications. One of the clients does not have a readable identification band in place. What should the nurse do?

Correct Answer: C

Rationale: Asking the roommate provides a reliable secondary identifier in the absence of a readable ID band, ensuring safe medication administration. Self-identification or bed tags are less secure.

Question 3 of 5

The nurse employed in a woman's health care clinic would be most concerned about which client statement?

Correct Answer: C

Rationale: Red, warm breast with indented skin suggests inflammatory breast cancer, requiring urgent evaluation. A mobile lump is often benign, nipple pain is common in breastfeeding, and cyclic nodules are typically hormonal.

Question 4 of 5

Propranolol is prescribed for an adult suspected to have Graves' disease. The nurse explains to the client that propranolol is prescribed for which purpose?

Correct Answer: D

Rationale: Propranolol, a beta-blocker, slows heart rate, controlling tachycardia in Graves' disease (hyperthyroidism). It does not affect thyroid activity, provide hormones, or regulate metabolism.

Question 5 of 5

A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?

Correct Answer: D

Rationale: Discontinue a new food that was added to the infant's diet just prior to the rash. New foods can be a cause of diaper dermatitis.

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