Question 1: A client with a spinal cord injury at T6 reports a pounding headache and profuse sweating. What is the nurse’s priority action?
Rationale: A pounding headache and sweating are signs of autonomic dysreflexia. Checking for bladder distention and relieving it can resolve the condition.
Question 2: A client with a history of seizures has an aura and begins to seize. What is the nurse’s immediate action?
Rationale: Turning the client to the side maintains an open airway and reduces the risk of aspiration during a seizure.
Question 3: A nurse is caring for a client with cirrhosis and ascites. Which intervention will most effectively reduce fluid accumulation?
Rationale: Restricting dietary sodium reduces fluid retention and is a key intervention in managing ascites in clients with cirrhosis.
Question 4: A client receiving intravenous morphine reports itching and nausea. What is the nurse’s best action?
Rationale: Itching and nausea are common side effects of morphine. The nurse should assess respiratory status to ensure safety before taking further actions.
Question 5: A client is prescribed digoxin for heart failure. Which finding should prompt the nurse to withhold the medication?
Rationale: Digoxin should be withheld if the client’s heart rate is below 60 bpm to avoid severe bradycardia.
