Answers | Latest Version | 2025/2026 |
Correct & Verified
What is the priority nursing action when a client develops shortness of breath and chest pain after
insertion of a central line?
✔✔Notify the provider immediately and prepare for possible pneumothorax.
Which electrolyte imbalance is most likely in a client with chronic kidney disease?
✔✔Hyperkalemia.
What is the most common sign of left-sided heart failure?
✔✔Crackles in the lungs.
Which dietary change is important for a client with celiac disease?
✔✔Avoid foods containing wheat, rye, and barley.
What is the first nursing action for a client with hypoglycemia who is alert and able to swallow?
✔✔Give 15 grams of fast-acting carbohydrate, such as juice.
1
,What finding should be reported immediately in a client after thyroidectomy?
✔✔Stridor or difficulty breathing.
Which position helps reduce intracranial pressure?
✔✔Head of bed elevated to 30 degrees.
What is the best nursing action for a client with a dislodged tracheostomy tube?
✔✔Insert the obturator and replace the tube.
What is the expected stool characteristic in a client with a new ileostomy?
✔✔Liquid stool.
What is the most important teaching point for a client taking warfarin?
✔✔Monitor INR regularly and avoid excessive vitamin K intake.
What is the nurse’s first action when a blood transfusion reaction is suspected?
✔✔Stop the transfusion immediately.
2
, Which symptom is common in a client with hypocalcemia?
✔✔Positive Chvostek’s sign.
What is the priority action when a chest tube becomes disconnected from the drainage system?
✔✔Place the tube in sterile water to maintain the water seal.
What is the primary purpose of an incentive spirometer after surgery?
✔✔Prevent atelectasis.
Which lab value should be monitored closely for a client taking furosemide?
✔✔Potassium.
What should the nurse do if a client with COPD becomes suddenly restless and confused?
✔✔Assess oxygen saturation and increase oxygen if needed.
Which type of isolation is required for a client with tuberculosis?
✔✔Airborne precautions.
3