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Questions 148

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Question 1 of 5

A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

Correct Answer: A

Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.

Question 2 of 5

The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply.

Correct Answer: B, C, D

Rationale: Viral hepatitis causes increased AST, elevated ammonia, and low serum albumin due to liver damage. ALT is typically increased, not decreased, and prothrombin time is prolonged.

Question 3 of 5

The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:

Correct Answer: A

Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.

Question 4 of 5

A child with achondroplasia will likely have which of the following physical characteristics?

Correct Answer: D

Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.

Question 5 of 5

The nurse is reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?

Correct Answer: A

Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.

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