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Questions 149

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Question 1 of 5

The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?

Correct Answer: A

Rationale: Staring at the mouth, answering loudly, and misunderstanding questions suggest hearing impairment (
A). Cognitive impairment (
B), vision impairment (
C), and anxiety (
D) do not typically present with these specific behaviors.

Question 2 of 5

A client is prescribed heparin 5,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin should the nurse administer?

Correct Answer: 0.5 mL

Rationale: Dose: 5,000 units. Concentration: 10,000 units/mL. Volume = 5,000 ÷ 10,000 = 0.5 mL per dose.

Question 3 of 5

The nurse is caring for a client with epilepsy who is to receive Dilantin 100 mg IV push. The client has an IV of D51/2NS infusing at 100 mL/hr. When administering the Dilantin, the nurse should first:

Correct Answer: C

Rationale: Dilantin is incompatible with dextrose solutions (D51/2NS), causing precipitation. Flushing with normal saline ensures compatibility and prevents complications.

Question 4 of 5

The nurse is auscultating a client's breath sounds. Low-pitched grating and rubbing are noted on inhalation and exhalation. What will the nurse chart under assessment findings?

Correct Answer: C

Rationale: Low-pitched grating/rubbing sounds indicate a pleural friction rub, often due to pleural inflammation.

Question 5 of 5

A client admitted with transient ischemia attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse's initial action?

Correct Answer: A

Rationale: Applying direct pressure to a hematoma at the arteriogram site controls bleeding and prevents further complications, making it the initial action.

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