Question

A nurse is caring for a client.

Answer 1

Correct Answers

Blank 1 Correct Option: complete blood count
Blank 2 Correct Option: sputum culture and sensitivity
Blank 3 Correct Option: blood cultures

Rationale :

🦠The client’s fever, purulent sputum, crackles, tachypnea, and hypoxemia strongly suggest an acute bacterial respiratory infection such as pneumonia.

🧪A complete blood count evaluates the white blood cell count, which helps determine the severity of the infectious and inflammatory response.

🔬A sputum culture and sensitivity identifies the respiratory pathogen and determines which antibiotic therapy is most effective.

🩸Because the client has hypotension, tachycardia, and fever, blood cultures are appropriate to evaluate possible bacteremia or sepsis, ideally before antibiotics are administered.

📌Core Message

A client with suspected severe bacterial pneumonia should undergo CBC, sputum culture, and blood cultures to evaluate infection severity and guide antimicrobial treatment.

Answer 2

Correct Answers:

"I will eat a carbohydrate snack before exercising.”

Rationale :

🍌A carbohydrate snack before exercise can help prevent exercise-induced hypoglycemia, particularly for clients using insulin.

⚡Exercise increases glucose utilization by skeletal muscles and can enhance insulin sensitivity, causing blood glucose to decrease.

⏰Clients should generally avoid exercising during the peak action of insulin because this increases the risk for hypoglycemia.

🚫Exercise should also be avoided when significant ketones are present, because physical activity can worsen hyperglycemia and ketosis.

📌Core Message

Clients using insulin may need carbohydrate intake before exercise to reduce the risk of exercise-related hypoglycemia.

Answer 3

Correct Answers:

Abdominal rigidity

Rationale :

🚨Abdominal rigidity after bowel surgery can indicate inadequate gastric or intestinal decompression, possible obstruction, or developing peritoneal irritation.

🧴An NG tube connected to low intermittent suction is intended to remove gastrointestinal secretions and reduce abdominal distention after surgery.

🟢Greenish-yellow drainage is an expected appearance because gastric drainage may contain bile and gastrointestinal secretions.

🧪An aspirate pH below 5 supports gastric placement, making this finding consistent with appropriate tube positioning and function.

📌Core Message

Abdominal rigidity in a postoperative client with an NG tube may indicate inadequate gastrointestinal decompression and requires prompt assessment.

Answer 4

Correct Answers:

Avocados

Rationale :

🥑An allergy to avocado is associated with latex-fruit syndrome, in which structurally similar proteins trigger cross-reactive allergic responses.

🧤Individuals with latex allergy can also react to foods such as banana, kiwi, avocado, and chestnut.

👉The reaction occurs because certain plant proteins share antigenic similarities with proteins found in natural rubber latex.

⚠️Identifying these food allergies can help nurses recognize clients who might be at increased risk for a latex hypersensitivity reaction during procedures.

📌Core Message

An avocado allergy can indicate increased risk for latex hypersensitivity because of cross-reactive plant proteins.

Answer 5

Correct Answers:

Apply ice on the ankle for 20 min intervals.

Rationale :

🧊Applying ice for approximately 20 minutes at a time during the acute period reduces pain, swelling, and inflammation following an ankle sprain.

🩹Cold causes local vasoconstriction, which helps reduce tissue edema and bleeding into injured tissues.

🦶Elevation is also beneficial, but the extremity should generally be raised above heart level, rather than specifically above the head.

⚠️Persistent numbness or tingling can suggest compromised neurovascular status and should not be considered an expected finding.

📌Core Message

Acute ankle sprains are initially managed with intermittent cold therapy to decrease pain and swelling.

Answer 6

Correct Answers:

Stabilize the cervical spine.

Rationale :

🦴A client involved in a motor-vehicle crash should be assumed to have a potential cervical spine injury until it has been ruled out.

🛡️Immediate cervical stabilization prevents unnecessary neck movement that could worsen an unstable spinal injury and produce spinal cord damage.

🌬️During the trauma primary survey, airway management is performed while maintaining cervical spine protection.

🚑Once spinal alignment is protected, the nurse can continue with oxygenation, circulation, vascular access, and temperature control based on the client’s findings.

📌Core Message

Following major trauma, immediate cervical spine protection is essential to prevent secondary spinal cord injury while the primary survey continues.

Answer 7

Correct Answers:

Allow the infant to suck on a pacifier during feedings.

Rationale :

🧴Allowing a 3-month-old infant to use a pacifier during tube feeding provides nonnutritive sucking, which supports normal oral development.

👶Nonnutritive sucking can help the infant associate sucking with satiety and feeding, potentially improving later transition to oral feeding.

🦠Large amounts of formula should not remain in the feeding container for prolonged periods because this increases bacterial contamination risk.

💧A 30 mL water flush is generally excessive for a young infant and may contribute to inappropriate fluid administration.

📌Core Message

Nonnutritive sucking during tube feeding supports normal oral development and helps maintain the infant’s association between sucking and feeding.

Answer 8

Correct Answers:

6 months

Rationale :

🦷The presence of lower central incisors is consistent with eruption beginning around 6 months of age.

🧍An infant around this age can typically bear substantial weight when supported in a standing position and increasingly develops purposeful hand control.

🧴Being able to hold a bottle is consistent with developmental abilities emerging around the middle of the first year.

🧠The disappearance of the Moro and tonic neck reflexes, combined with inability to sit completely unsupported, also supports an age near 6 months.

📌Core Message

The combination of lower central incisors, disappearing primitive reflexes, supported weight bearing, and emerging bottle control is most consistent with a 6-month-old infant.

Answer 9

Correct Answers:

Infuse 0.9% sodium chloride IV.

Rationale :

🚨A suspected acute hemolytic transfusion reaction requires immediate discontinuation of the blood transfusion to prevent further exposure to incompatible blood cells.

💧The nurse should maintain IV access using 0.9% sodium chloride through new tubing so emergency medications and fluids can be administered safely.

🩸A hemolytic reaction can cause intravascular hemolysis, hypotension, acute kidney injury, and shock, making rapid intervention essential.

🧪The nurse should also notify the provider and blood bank while obtaining required blood and urine specimens according to facility protocol.

📌Core Message

During an acute hemolytic transfusion reaction, stop the blood immediately and maintain vascular access with 0.9% sodium chloride while initiating emergency evaluation.

Answer 10

Correct Answers:

Social worker

Rationale :

🤝A social worker assists clients and families with psychosocial needs, counseling resources, and referrals for family therapy.

🏠Social workers evaluate family dynamics, community resources, financial concerns, and support systems that can affect health outcomes.

🧠They can coordinate referrals to qualified mental health professionals who provide individual, marital, or family counseling.

📞The community health nurse therefore appropriately collaborates with the social worker when a client requests assistance accessing family therapy.

📌Core Message

A social worker is the appropriate interdisciplinary professional to coordinate access to family counseling and psychosocial services.

1 :
A nurse is caring for a client.

Correct Answers

2 :
A nurse is teaching a client who has diabetes mellitus about exercise safety. Which of the following client statements indicates an understanding of the teaching?

3 :
A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?

4 :
A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex?

5 :
A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. Which of the following should the nurse include in the teaching?

6 :
A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following actions should the nurse take first?

7 :
A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?

8 :
A nurse is admitting an unidentified female infant who was brought to the emergency department.

Answer Options

9 :
A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

10 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

1 : A nurse is caring for a client.

Correct Answers

2 : A nurse is teaching a client who has diabetes mellitus about exercise safety. Which of the following client statements indicates an understanding of the teaching?

3 : A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?

4 : A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex?

5 : A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. Which of the following should the nurse include in the teaching?

6 : A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following actions should the nurse take first?

7 : A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?

8 : A nurse is admitting an unidentified female infant who was brought to the emergency department.

Answer Options

9 : A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

10 : A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

1 :
A nurse is caring for a client.

2 :
A nurse is teaching a client who has diabetes mellitus about exercise safety. Which of the following client statements indicates an understanding of the teaching?

3 :
A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?

4 :
A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex?

5 :
A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. Which of the following should the nurse include in the teaching?

6 :
A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following actions should the nurse take first?

7 :
A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?

8 :
A nurse is admitting an unidentified female infant who was brought to the emergency department.

9 :
A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

10 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?