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Questions 149

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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 or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.

Question 2 of 5

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:

Correct Answer: B

Rationale: Dressing in extra layers of clothing is a safe and effective way to manage cold intolerance in hypothyroidism, avoiding risks associated with electric blankets or heating pads.

Question 3 of 5

The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

Correct Answer: D

Rationale: Nausea is the most common side effect of rivastigmine, a cholinesterase inhibitor used for Alzheimer's disease.

Question 4 of 5

The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation, increasing the risk of urinary retention, so hourly voiding is encouraged.

Question 5 of 5

The nurse is caring for a client with a tracheostomy tube in place. During tracheostomy care, the nurse accidentally dislodges the tube. Which of the following actions should the nurse take FIRST?

Correct Answer: A

Rationale: immediate reinsertion of a tracheostomy tube is critical to maintain airway patency

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