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Questions 158

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Question 1 of 5

Which finding is the best indication that a client with ineffective airway clearance needs suctioning?

Correct Answer: C

Rationale: Adventitious breath sounds (e.g., rhonchi, wheezing) indicate mucus obstruction, signaling the need for suctioning. Oxygen saturation, respiratory rate, and ABGs are less specific.

Question 2 of 5

The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

Correct Answer: C

Rationale: Gingival hyperplasia (overgrown gums) is a common side effect of phenytoin (Dilantin). Irritability, excessive sleep, and weight gain are not typical side effects of this medication.

Question 3 of 5

The nurse is caring for a client with a history of atrial fibrillation. Which medication is most likely to be prescribed to prevent thromboembolism?

Correct Answer: A

Rationale: Warfarin is commonly prescribed for atrial fibrillation to prevent thromboembolism by maintaining anticoagulation (target INR 2–3). Aspirin and clopidogrel are less effective, and heparin is used short-term.

Question 4 of 5

A newborn weighing 7 pounds at birth should be expected to weigh pounds by one year of age.

Correct Answer: 21 pounds

Rationale: Newborns typically triple their birth weight by one year. 7 lbs × 3 = 21 lbs.

Question 5 of 5

The nurse is caring for a client with acquired immunodeficiency syndrome. Which finding should be reported to the doctor immediately?

Correct Answer: D

Rationale: A respiratory rate of 26 breaths per minute suggests respiratory distress, a critical issue in AIDS due to possible opportunistic infections like Pneumocystis pneumonia, requiring immediate reporting.

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