Answers (100% Latest & Verified Correct Answers)
QUESTION 1
A nurse is assessing a client who has received an antibiotic. The nurse
should identify which of the following findings as an indication of a
possible allergic reaction to the medication?
A. Bradycardia
B. Headache
C. Joint pain
D. Hypotension
VERIFIED ANSWER: D. Hypotension
Rationale: Hypotension can indicate an anaphylactic reaction to
antibiotics, which is a severe allergic response. Other signs of allergic
reaction include urticaria, pruritus, wheezing, and angioedema.
Bradycardia, headache, and joint pain are not typical signs of an
allergic reaction.
QUESTION 2
A nurse on a mental health unit is caring for a client who has
schizophrenia and is experiencing auditory hallucinations telling them
to hurt others. The client is refusing to take anti-psychotic medication.
Which of the following responses should the nurse make?
,A. "You should plan to take this medication for a few weeks."
B. "You will regret it if you do not take this medication."
C. "This medication will help you respond to the voices."
D. "This medication will help you stop the voices you are hearing."
VERIFIED ANSWER: D. "This medication will help you stop the
voices you are hearing."
Rationale: This response addresses the client's concern about the
hallucinations directly and provides hope that the medication will help
with the specific symptom. It is honest and therapeutic, focusing on the
benefit for the client.
QUESTION 3
A nurse is providing care for a patient who has depression and is to
have electroconvulsive therapy. Which of the following conditions
should the nurse identify as increasing the client's risk for
complications?
A. Hyperthyroidism
B. Renal calculi
C. Diabetes mellitus
D. Cardiac dysrhythmias
VERIFIED ANSWER: D. Cardiac dysrhythmias
Rationale: ECT causes significant cardiovascular changes including
bradycardia, tachycardia, and hypertension. Clients with pre-existing
,cardiac dysrhythmias are at increased risk for complications during
ECT and require careful cardiac monitoring.
QUESTION 4
A nurse is reviewing the laboratory results of a client who has
rheumatoid arthritis. Which of the following findings should the nurse
report to the provider?
A. WBC count 8,000/mm³
B. Platelets 150,000/mm³
C. Aspartate aminotransferase 10 units/L
D. Erythrocyte sedimentation 75 mm/hr
VERIFIED ANSWER: D. Erythrocyte sedimentation 75 mm/hr
Rationale: An ESR of 75 mm/hr is significantly elevated (normal is
typically 0-20 mm/hr for women, 0-15 mm/hr for men). In a client with
rheumatoid arthritis, this indicates active inflammation and disease
activity that requires provider notification and possible treatment
adjustment.
QUESTION 5
A nurse is suctioning the airway of a client who is receiving mechanical
ventilation via an endotracheal tube. Which of the following findings
should the nurse identify as an indication that suctioning has been
effective?
, A. Presence of a productive cough
B. Decreased peak inspiratory pressure
C. Thinning of mucous secretions
D. Flattening of the artificial airway cuff
VERIFIED ANSWER: B. Decreased peak inspiratory pressure
Rationale: Effective suctioning removes secretions from the airway,
which decreases resistance to airflow. This results in decreased peak
inspiratory pressure on the ventilator, indicating improved airway
patency and ventilation.
QUESTION 6
A nurse is caring for a client who is in a seclusion room following
violent behavior. The client continues to display aggressive behavior.
Which of the following actions should the nurse take?
A. Stand within 30 cm (1 ft) of the client when speaking with them.
B. Express sympathy for the client's situation.
C. Confront the client about his behavior.
D. Speak assertively to the client.
VERIFIED ANSWER: D. Speak assertively to the client.
Rationale: Assertive communication sets clear boundaries while
maintaining respect. Confrontation may escalate behavior; standing too
close invades personal space and may increase agitation; expressing
sympathy may not address the behavior effectively.