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Showing all 10 practice questions with expert explanatory rationales.
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
Expert Explanatory Rationale
Correct Answer: Hepatotoxicity.
Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?
Expert Explanatory Rationale
Correct Answer: Administer surfactant
Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.
You are caring for a group of elderly clients, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these clients some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a (n):
Expert Explanatory Rationale
Correct Answer: Decreased hepatic metabolism.
Elderly individuals often have decreased hepatic metabolism due to reduced liver function, which affects drug metabolism and increases the risk of side effects, adverse reactions, and toxicity.
The nurse teaches a pregnant client to perform Kegel exercises. Which statement by the client indicates an understanding of the purpose of these types of exercises?
Expert Explanatory Rationale
Correct Answer: The exercises will help strengthen the pelvic floor.
Kegel exercises assist in strengthening the pelvic floor (pubococcygeal muscle). Pelvic tilt exercises help reduce backaches. Leg elevation assists in preventing ankle edema. Instructing a client to drink 8 ounces of fluids 6 times a day helps prevent urinary tract infections.
A 9-year-old child is scheduled for an electromyelogram. To prepare the child for this procedure, what should the nurse do?
Expert Explanatory Rationale
Correct Answer: Verbally explain what will be done during the test.
A verbal explanation in age-appropriate terms helps a 9-year-old understand the procedure, reducing anxiety and promoting cooperation.
A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety?
Expert Explanatory Rationale
Correct Answer: Observe vital signs and oxygen saturation periodically during activity.
Monitoring vital signs and oxygen saturation during activity ensures the nurse can detect early signs of respiratory distress or hypoxia, promoting client safety. Encouraging deep, rapid breathing may exacerbate dyspnea and is not safe. Providing environmental stimulation is unrelated to respiratory safety.
Scheduling activities before respiratory medications or treatments could worsen dyspnea, as these interventions improve breathing capacity.
The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?
Expert Explanatory Rationale
Correct Answer: Tubing clamped near the insertion site.
Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.
A client has been prescribed transcutaneous electrical nerve stimulation (TENS) by the primary health care provider for the relief of chronic pain. Which statement by the client would indicate to the nurse a need for further teaching regarding this pain relief measure?
Expert Explanatory Rationale
Correct Answer: I am not real happy that I have to stay in the hospital for this treatment.
It is not necessary for the client to remain in the hospital for this treatment. The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes.
A client with a history of liver failure is prescribed lactulose (Cephulac). The nurse should monitor the client for which of the following therapeutic effects?
Expert Explanatory Rationale
Correct Answer: Decreased ammonia levels.
Lactulose reduces ammonia levels by promoting its excretion in hepatic encephalopathy.
The nurse is caring for a client with a venous leg ulcer. Which of the following interventions should be included in the plan of care?
Expert Explanatory Rationale
Correct Answer: Apply compression bandages.
Compression bandages promote venous return and healing in venous leg ulcers.
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