Question

47. A nurse is assessing a client following extubating from a ventilator. For which of the following findings should the nurse intervene immediately?

1. SaO2 92%
2. Stridor
3. Sore throat
4. Rhonchi

48. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

1. Normotensive blood pressure
2. Absence of a bruit
3. Dilated appearance of the graft
4. Palpable thrill

49. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client

reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

1. Check the client's urine output.
2. Administer PRN pain medication
3. Increase the client's fluid intake.
4. Reposition the client in bed,

50. A nurse is caring for a client who is the caregiver for a relative who has a chronic disease. Which of the following statements indicates the client is

adapting to the role change?

1. "I need to get my blood pressure medicine refilled."
2. had to reschedule my doctor's appointment last week."
3. "I've lost 15 pounds in the past 2 months."
4. "I have lunch with my friends once a week."

Answer 1

Question 1

Correct answer: option a

Rational

Option a:

Normal saturation range should be more than 95%. In this scenario patient saturation is 92%, this indicates patient need some emergency measure like oxygen administration and continuous monitoring. So option a is correct answer.

Option b: Stridor indicates laryngeal edema, this also can occur as a complications of post extubation its managed by corticosteroids. This is consider as second priority of management. So option b is incorrect.

Option c: Sore throat and Rhonchi management comes as next priority management. So its incorrect.

Question 2

Correct answer: option d

Rational:

Option d: Presence of Palpable thrill indicates proper functioning and patency of arteriovenous graft. So option d is correct answer.

Option a: Normotensive pressure is not a indicator of arterio venous graft. So its incorrect.

Option b and c: Absence bruit and dilated graft both are indicates the symptoms if graft failure. So its not a correct answer.

Question 3

Correct answer: option a

Rational

Option a: in case of continuous bladder irrigation if patient develops abdominal pain that indicates issues with outflow of irrigation channel. So check the urine output for any obstruction is correct management. So option a is correct.

Option b: Administration of Prn medication is not a appropriate action. So its not a correct answer.

Option c: increase fluid intake, which promote further discomfort. So its not a proper management.

Option d: Reposition the client also considered as unnecessary action. So its incorrect.

Question 4

Correct answer :option d

Rational:

Option d: have lunch with my friends once a week is positive statement which indicates the adoption with chronic diseases. So its correct option.

Option a, b,c: these options are negative statement. Its not indicating the disease adaptation. So its incorrect.