75 items MS Random Questions with Answers and Rationale

C) Client reports prickling sensation in the right hand

D) Slight swelling of fingers of right hand

The correct answer is C: Prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

16. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

A) Liver function

B) Kidney function

C) Blood sugar

D) Cardiac enzymes

The correct answer is A: INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

17. Which client is at highest risk for developing a pressure ulcer?

A) 23 year-old in traction for fractured femur

B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance

C) 75 year-old with left sided paresthesia and is incontinent of urine and stool

D) 30 year-old who is comatose following a ruptured aneurysm

The correct answer is C: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

18. Which contraindication should the nurse assess for prior to giving a child immunization?

A) Mild cold symptoms

B) Chronic asthma

C) Depressed immune system

D) Allergy to eggs

The correct answer is C: Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.

19. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

A) Neurotoxicity

B) Hepatomegaly

C) Nephrotoxicity

D) Ototoxicity

The correct answer is C: Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

20. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?

A) Protect the eyes of the neonate from the heat lamp

B) Monitor the neonate's temperature

C) Warm all medications and liquids before giving

D) Avoid touching the neonate with cold hands

The correct answer is B: When using a warming device the neonate's temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.