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The nurse is caring for a client with a history of anaphylaxis.
- A. Which instruction is most important for a client with a history of anaphylaxis?
- B. Carry an epinephrine auto-injector at all times.
- C. Avoid over-the-counter medications.
- D. Wear loose-fitting clothing.
- E. Monitor blood pressure daily.
Correct Answer: A
Rationale: Carrying an epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Avoiding medications, wearing loose clothing, and monitoring blood pressure are less urgent.
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The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions should the nurse prioritize?
- A. Encourage arm exercises on the affected side.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and promote mobility post-mastectomy. Options B, C, and D are secondary.
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.
The nurse is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
- A. Visual status
- B. Ambulatory difficulty
- C. Orientation to time, place, and person
- D. Understanding of the English language
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.
The nurse is preparing to administer a medication to a client via a nasogastric tube. Which of the following actions should the nurse perform FIRST?
- A. Check the placement of the nasogastric tube.
- B. Crush the medication and mix with water.
- C. Flush the tube with 30 mL of water.
- D. Position the client in a supine position.
Correct Answer: A
Rationale: Verifying nasogastric tube placement prevents aspiration, a priority before medication administration. Options B, C, and D follow placement confirmation.
The nurse discovers that a hospitalized client is not breathing and has no pulse. After calling for help, what should the nurse do next?
- A. Give the client two breaths
- B. Administer five chest compressions
- C. Go get the emergency cart
- D. Defibrillate the client
Correct Answer: A
Rationale: Per CPR guidelines, after calling for help, provide two rescue breaths if trained, followed by compressions. Fetching the cart or defibrillating delays resuscitation.