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Questions 149

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Extract:


Question 1 of 5

Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?

Correct Answer: B

Rationale: Venous insufficiency causes stasis ulcers, typically over the medial malleolus, due to venous pooling and tissue breakdown.

Question 2 of 5

The nurse has an order to administer 100 units of regular insulin in 500 mL of 0.9% NS to infuse at 12 units per hour. The nurse should program the IV pump to deliver how many mLs per hour?

Correct Answer: 60

Rationale: Concentration: 100 units/500 mL = 0.2 units/mL.
To deliver 12 units/hour: 12 ÷ 0.2 = 60 mL/hour.

Question 3 of 5

What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?

Correct Answer: A

Rationale: Glomerulonephritis often causes hypertension due to fluid retention and renal dysfunction.

Question 4 of 5

Which task should be assigned to the nursing assistant?

Correct Answer: C

Rationale: Feeding a client with dementia is within the nursing assistant's scope, as it involves basic care and does not require advanced skills.

Question 5 of 5

A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?

Correct Answer: A

Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (
A). Notifying the physician (
B) or encouraging coughing (
C) is secondary, and irrigation (
D) is not typically the initial step.

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