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Questions 158

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Question 1 of 5

A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a small-bore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:

Correct Answer: C

Rationale: A chest x-ray is the most reliable method to confirm small-bore feeding tube placement, as other methods may be inconclusive or unreliable.

Question 2 of 5

A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:

Correct Answer: D

Rationale: Before giving any emetic, the substance ingested must be known. At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. Vomiting should never be induced in an unconscious client because of the risk of aspiration.

Question 3 of 5

The nurse is caring for a client with a history of psoriasis. The nurse should expect the client to have:

Correct Answer: A

Rationale: Psoriasis causes scaly, silvery plaques due to rapid skin cell turnover, a hallmark symptom.

Question 4 of 5

A client with a history of a heart transplant is receiving Cyclosporine (Sandimmune). The nurse should monitor the client for:

Correct Answer: A

Rationale: Cyclosporine suppresses immunity, increasing infection risk, requiring vigilant monitoring. Hypotension, hyperkalemia, and weight loss are less common.

Question 5 of 5

The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?

Correct Answer: B

Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (
A) and anxiety (
C) are common in both, and normal temperature (
D) is nonspecific.

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