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Questions 164

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Question 1 of 5

While the nurse is preparing medications, a code occurs. One of the nursing assistants offers to help by administering the medications. What is the best response by the nurse?

Correct Answer: B

Rationale: Holding medications prioritizes the code response, as CNAs cannot administer medications, ensuring patient safety and appropriate task delegation.

Question 2 of 5

The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?

Correct Answer: C

Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.

Question 3 of 5

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?

Correct Answer: A

Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.

Question 4 of 5

The nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection?

Correct Answer: C

Rationale: An indwelling urinary catheter increases the risk of catheter-associated urinary tract infections, a common nosocomial infection, especially in older adults with prolonged catheter use.

Question 5 of 5

The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?

Correct Answer: B

Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.

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