CPNRE Complex Care 2

Question 1

A client post-abdominal surgery reports sudden severe abdominal pain with board-like rigidity. What is the priority nursing action?

Accepted Answer

Position in semi-Fowlers and notify the physician immediately

Answer

Administer analgesic and reassess in 30 minutes

Answer

Apply warm compress and continue monitoring

Answer

Document and report at end of shift

Question 2

A client with Type 1 diabetes has blood glucose 2.8 mmol/L with diaphoresis and trembling. Which intervention has priority?

Accepted Answer

Give 15 grams of fast-acting carbohydrate if the client can swallow safely

Answer

Administer insulin as ordered

Answer

Start IV normal saline immediately

Answer

Hold all insulin until glucose normalizes

Question 3

A client with chronic renal failure on a potassium-restricted diet selects which food that requires correction?

Accepted Answer

Orange juice and a banana

Answer

White rice with butter

Answer

White bread with cream cheese

Answer

Apple sauce and white crackers

Question 4

A client develops chills, fever, and back pain 20 minutes into a blood transfusion. What is the first nursing action?

Accepted Answer

Stop the transfusion immediately and maintain IV access with normal saline

Answer

Slow the rate and notify the physician

Answer

Give antipyretic and continue at the same rate

Answer

Document and continue monitoring

Question 5

A client with left-sided stroke has left hemiplegia and dysphagia. Which meal positioning is most appropriate?

Accepted Answer

Upright at 90 degrees with head turned toward the weaker side

Answer

Semi-reclined at 30 degrees

Answer

Left lateral position with head elevated

Answer

Tilt head back to open the airway

Question 6

A family member is about to activate the PCA button for a sleeping client. What is the correct nursing response?

Accepted Answer

Educate the family that only the client should activate the PCA and explain the safety reasons

Answer

Allow it since the family knows when the client needs pain relief

Answer

Disconnect the PCA since the family is misusing it

Answer

Notify the physician to discontinue the PCA