The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?

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Question 1 of 5

The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?

Correct Answer: D

Rationale: Client unable to speak is expected with an ET tube and doesn't require immediate action; however, if misinterpreted, bilateral breath sounds missing would. The question likely intends a critical finding assume typo. A (if absent) would prompt action, per airway standards, but as written, D is normal.

Question 2 of 5

A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to

Correct Answer: B

Rationale: ABCs (airway, breathing, circulation) take priority to stabilize the client before decontamination.

Question 3 of 5

When caring for a client with urinary incontinence, which content should be reinforced by the nurse?

Correct Answer: D

Rationale: Antihistamines can worsen incontinence by reducing bladder tone; other options are incorrect or harmful.

Question 4 of 5

A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?

Correct Answer: C

Rationale: Humulin N (intermediate-acting insulin) is not given IV; only regular insulin is safe IV, indicating an error.

Question 5 of 5

The use of atropine for treatment of symptomatic bradycardia is contraindicated for a client with which of the following conditions?

Correct Answer: B

Rationale: Atropine increases intraocular pressure, worsening glaucoma.

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