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Questions 164

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Extract:


Question 1 of 5

A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?

Correct Answer: A

Rationale: Elbow. The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.

Question 2 of 5

The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

Correct Answer: A

Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.

Question 3 of 5

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

Correct Answer: D

Rationale: Occlusive moist dressing. This supports healing by maintaining a moist environment for granulation tissue.

Question 4 of 5

Which of the following is not considered one of the five rights of medication administration?

Correct Answer: D

Rationale: Dose, client, drug, route and time are considered the five rights of medication.

Question 5 of 5

A 54-year-old male is admitted to the cardiac unit with chest pain radiating to the jaw and left arm. Which enzyme would be most specific in the diagnosis of a myocardial infarction?

Correct Answer: D

Rationale: CK-MB (creatine phosphokinase muscle bond isoenzyme) is the most specific for a myocardial infarction. Troponin is also extremely reliable. Answers A, B, and C are nonspecific to myocardial infarctions, so they are incorrect.

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