Question 1: A client with a chest tube following a pneumothorax reports increased shortness of breath. What is the nurse’s priority action?
Rationale: Assessing the chest tube for kinks or blockages is the priority to ensure it is functioning properly and preventing complications like tension pneumothorax.
Question 2: A client with a new prescription for metformin asks about its primary function. What is the nurse’s best response?
Rationale: Metformin primarily works by decreasing glucose production in the liver and improving insulin sensitivity.
Question 3: A nurse is caring for a client with increased intracranial pressure (ICP). Which intervention should the nurse prioritize?
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain and helps reduce ICP.
Question 4: A client with a history of alcohol abuse is admitted with confusion, ataxia, and nystagmus. Which intervention is most critical?
Rationale: Administering thiamine is critical to prevent or treat Wernicke’s encephalopathy, a serious neurological condition associated with alcohol abuse.
Question 5: A client reports chest pain after eating a heavy meal. The nurse suspects gastroesophageal reflux disease (GERD). Which client statement supports this suspicion?
Rationale: Pain worsening when lying down is a classic symptom of GERD, as stomach acid can more easily reflux into the esophagus.
