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Questions 158

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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 client is admitted with a diagnosis of gestational diabetes. Which fetal monitoring technique is most appropriate?

Correct Answer: C

Rationale: Gestational diabetes increases fetal risks (e.g. macrosomia hypoglycemia) requiring close monitoring. Non-stress tests assess fetal heart rate and biophysical profiles evaluate fetal well-being comprehensively. Both are appropriate.

Question 4 of 5

The physician has ordered a 24-hour urine collection for a client. Which instruction should the nurse provide?

Correct Answer: A

Rationale: For a 24-hour urine collection, the first void is discarded, and all subsequent urine is collected for exactly 24 hours to ensure accurate measurement of analytes. A single container is used, refrigeration is advised, but separate voids are not needed.

Question 5 of 5

The nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most indicative?

Correct Answer: B

Rationale: A warm, red, swollen calf is a classic sign of DVT due to clot-related inflammation. Bilateral edema (
A) suggests heart failure, cramping (
C) is nonspecific, and pale/cool foot (
D) indicates arterial occlusion.

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