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Questions 158

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Extract:


Question 1 of 5

A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

Correct Answer: B

Rationale: Swallowing assists with insertion of tube and closes off airway.

Question 2 of 5

The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?

Correct Answer: C

Rationale: The client admitted one hour ago with rales and shortness of breath indicates potential acute respiratory distress, possibly from pulmonary edema or pneumonia, requiring immediate assessment. The other clients are stable or less urgent.

Question 3 of 5

The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?

Correct Answer: C

Rationale: Using a heat lamp is incorrect and could cause burns or delay healing. Petroleum gauze, cleaning, and monitoring for infection are appropriate circumcision care practices.

Question 4 of 5

A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:

Correct Answer: A

Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.

Question 5 of 5

The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?

Question Image

Correct Answer: A, B, C, D, E, G

Rationale: Elevated commode seats (
A), removing rugs (
B), grab bars (
C), medic alert monitors (
D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.

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