Extract:

Question 1 of 5

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?

A. Suction the client's airway every 4 hr.B. Secure the endotracheal tube to the client's lower jaw.C. Monitor the client's cuff pressure every 8 hr.D. Place the client in a prone position.

Correct Answer: C

Rationale: Monitoring cuff pressure every 8 hours prevents tracheal damage from overinflation. Suctioning is as needed, securing isn't to the jaw, and prone positioning depends on condition.

Question 2 of 5

A nurse is caring for a client who has a prescription for isoniazid. Which of the following actions should the nurse take?

A. Administer the medication via rapid IV push.B. Monitor the client for signs of hepatotoxicity.C. Dilute the medication in dextrose 5% in water.D. Instruct the client to take the medication once per week.

Correct Answer: B

Rationale: Isoniazid risks liver damage (hepatotoxicity), requiring monitoring (e.g., LFTs). It's oral, not IV, and taken daily for TB treatment.

Question 3 of 5

A nurse is caring for a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include in the teaching?

A. You should store the tablets in the refrigerator.B. You should take one tablet every 10 minutes until the pain stops.C. You might notice a tingling sensation under your tongue.D. You should swallow the tablet with a full glass of water.

Correct Answer: C

Rationale: Nitroglycerin causes a tingling sensation sublingually, indicating absorption. It's stored at room temp, taken every 5 minutes up to 3 doses, and not swallowed.

Question 4 of 5

A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?

A. TriiodothyronineB. Blood urea nitrogenC. Arterial blood gasesD. Prothrombin time

Correct Answer: D

Rationale: Warfarin affects clotting via vitamin K, so prothrombin time (PT) monitors its efficacy and safety. Other tests assess thyroid, kidney, or respiratory function, not anticoagulation.

Question 5 of 5

A nurse is assisting with the care of a client who is postoperative following a craniotomy. Which of the following actions should the nurse take?

A. Keep the head of the bed flat.B. Monitor the client for signs of increased intracranial pressure.C. Instruct the client to cough forcefully every 2 hr.D. Apply a warm compress to the surgical site.

Correct Answer: B

Rationale: Increased intracranial pressure (e.g., pupil changes) is a risk post-craniotomy, requiring monitoring. Elevation, gentle coughing, and no heat are standard.