Extract:

Question 1 of 5

Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?

Correct Answer: B

Rationale: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.

Question 2 of 5

Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?

A. To promote oxygen intake. B. To strengthen the diaphragm. C. To strengthen the intercostal muscles. D. To promote carbon dioxide elimination.

Correct Answer: D

Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.

Question 3 of 5

The nurse is reading the results of a tuberculin skin test (see fi gure). The nurse should interpret the results as:

A. Negative B. Needing to be repeated. C. Positive. D. False.

Correct Answer: C

Rationale: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purifi ed protein derivative (PP
D) by measuring the size of the fi rm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a fi rm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false.

Question 4 of 5

The client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure, which does the nurse assess first?

A. Vital signs. B. The incision. C. The airway. D. The neurologic signs.

Correct Answer: C

Rationale: After a cervical lymph node biopsy, the nurse should first assess the airway, as swelling or hematoma in the neck could compromise breathing. Vital signs, incision, and neurologic signs are assessed next.

Question 5 of 5

The nurse teaches the client with chronic cancer pain about optimal pain control. Which of the following recommendations is most effective for pain control?

A. Get used to some pain and use a little less medication than needed to keep from being addicted. B. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. C. Take analgesics only when pain returns. D. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain.

Correct Answer: B

Rationale: Taking analgesics around-the-clock prevents recurrent pain by maintaining steady drug levels, which is the most effective strategy for chronic cancer pain.