Question 1: A nurse is caring for a client with a spinal cord injury at T4. Which assessment finding requires immediate action?
Rationale: A blood pressure of 200/120 mmHg indicates autonomic dysreflexia, a life-threatening emergency in clients with spinal cord injuries.
Question 2: A client with a deep vein thrombosis (DVT) reports sudden chest pain and shortness of breath. What is the nurse’s priority action?
Rationale: Sudden chest pain and shortness of breath suggest a pulmonary embolism. Placing the client in high Fowler’s position improves oxygenation.
Question 3: A nurse is preparing to administer medications to a client with chronic kidney disease. Which medication should the nurse question?
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are nephrotoxic and should be avoided in clients with chronic kidney disease.
Question 4: A client with hypothyroidism is experiencing cold intolerance, weight gain, and fatigue. What lab value does the nurse expect?
Rationale: An elevated TSH indicates hypothyroidism, as the pituitary gland produces more TSH to stimulate an underactive thyroid.
Question 5: A nurse is caring for a client who has been prescribed a low-residue diet. Which food is appropriate for this diet?
Rationale: A low-residue diet limits fiber. Baked chicken is low in fiber and suitable for this diet.
