Nokea
An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?
- A. Ask the pregnant daughter to leave the room and have the wife assist in holding the client.
- B. Have the client wear a lead apron over his chest and abdomen.
- C. Close the door to the room securely during the x-ray.
- D. Ask the wife and daughter to leave the room.
Correct Answer: D
Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.
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Which of the following is a common complaint of the client with end-stage renal failure?
- A. Weight loss
- B. Itching
- C. Ringing in the ears
- D. Bruising
Correct Answer: B
Rationale: Itching is common in end-stage renal failure due to uremia and phosphate accumulation. Weight loss , tinnitus , and bruising are less specific.
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
- A. Slow the IV and raise the head of the bed
- B. Call the physician
- C. Take the client's blood pressure
- D. Notify the charge nurse
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.
A client with a history of asthma is admitted with severe shortness of breath and cyanosis. Which finding would indicate that the client is experiencing status asthmaticus?
- A. Increased vocal fremitus
- B. Silent chest on auscultation
- C. Stridor during inspiration
- D. Rhonchi in bilateral lung fields
Correct Answer: B
Rationale: Silent chest on auscultation indicates severe airway obstruction with minimal air movement, a hallmark of status asthmaticus, requiring immediate intervention.
The nurse reinforces teaching for a client taking atorvastatin to call the health care provider if experiencing which symptom associated with a serious adverse effect of the medication?
- A. Diarrhea
- B. Headache
- C. Muscle aches
- D. Numbness in the feet
Correct Answer: C
Rationale: Muscle aches may indicate myopathy or rhabdomyolysis, serious atorvastatin side effects requiring immediate attention. Diarrhea, headaches, and numbness are less specific or unrelated.
The nurse is reinforcing teaching with a client who has a new prescription for Rh immunoglobulin. The client has an Rh-negative blood type and gave birth 24 hours ago to a newborn who has an Rh-positive blood type. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I need the medication now because the dose I received during pregnancy was ineffective
- B. I can receive the medication at my follow-up appointment in 6 weeks
- C. I need to have a blood specimen obtained in 3 months to verify that the medication was effective
- D. I will receive the medication to prevent my body from forming antibodies
Correct Answer: D
Rationale: Rh immunoglobulin prevents antibody formation against Rh-positive fetal blood, given within 72 hours postpartum. The prenatal dose is separate, 6 weeks is too late, and 3-month testing is not standard.