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Question 1 of 5

A 2-month-old boy with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that her son had a DPT injection one week ago, and asks if this fever is related to the immunization. The nurse’s response should be based on the knowledge that

Correct Answer: C

Rationale: low-grade fever and irritability frequent response to immunization

Question 2 of 5

A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication?

Correct Answer: B

Rationale: Increased thirst and urination suggest lithium toxicity, which can cause diabetes insipidus-like symptoms, requiring immediate attention.

Question 3 of 5

A client has been undergoing treatment for an aggressive cancer. The physicians have stated the chance of recovery is very unlikely. The client states that she prefers to cease all treatments and start palliative care. The nurse supports this decision based on which ethical principle?

Correct Answer: D

Rationale: Autonomy respects the client’s right to make decisions about their treatment, including choosing palliative care over continued aggressive therapy.

Question 4 of 5

The physician has ordered increased oral hydration for a client with renal calculi. Unless contraindicated, the recommended oral intake for helping with the removal of renal calculi is:

Correct Answer: D

Rationale: A fluid intake of 200 mL per hour promotes urine output to facilitate stone passage.

Question 5 of 5

A 20-year-old woman who has been laboring at home for several hours has been admitted to the labor and delivery unit at the hospital. The nurse has come in to assess her progress. Which of the following is indicative of being in the active phase of labor?

Correct Answer: A

Rationale: The active phase of labor involves cervical dilation of 4-7 cm with contractions 3-5 minutes apart lasting 40-60 seconds. Option A fits this description.

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