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Questions 164

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Question 1 of 5

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?

Correct Answer: C

Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.

Question 2 of 5

A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report:

Correct Answer: A

Rationale: Erythropoietin can increase blood viscosity, raising the risk of hypertension or thrombosis, which may present as a severe headache. Slight nausea , decreased urination , and itching are less specific or urgent.

Question 3 of 5

The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?

Correct Answer: A

Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.

Question 4 of 5

The nurse is reinforcing discharge teaching for a client who has a low health literacy level. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: B,C,D

Rationale: Teach-back confirms understanding, repeating key points reinforces learning, and visual aids simplify concepts. Excessive detail overwhelms low-literacy clients, and loud speech is unnecessary unless hearing-impaired.

Question 5 of 5

A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is

Correct Answer: D

Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

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