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Questions 164

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Extract:


Question 1 of 5

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?

Correct Answer: D

Rationale: Verifying the glucose result personally (
D) provides evidence of falsification. Asking a client (
A) is unreliable, a staff meeting (
B) is too general, and a warning (
C) is premature without proof.

Question 2 of 5

The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?

Correct Answer: A

Rationale: Lumbar punctures are typically performed in a lateral or sitting position, not prone (
A), requiring clarification. Urinating beforehand (
B), needle insertion (
C), and transient pain (
D) are correct.

Question 3 of 5

A woman is pregnant for the first time and is Rh negative. Her husband is Rh positive. She tells the nurse that he is very worried about her baby. Which information should the nurse plan to include when talking with this woman?

Correct Answer: A

Rationale: The first Rh-positive baby is typically unaffected as maternal antibodies develop post-delivery. RhoGAM is given after birth to prevent issues in future pregnancies, not after the second baby.

Question 4 of 5

A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?

Correct Answer: D

Rationale: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.

Extract:

Vital signs
Blood pressure 105/60 mm Hg
Heart rate 80/min
Respirations 22/min
SpO2 90% on room air
Nurse notes
The client has a history of coronary artery disease and peripheral vascular disease. Nursing assessment reveals crackles in middle & lower lung fields, moderate jugular venous distension, and 3+ pedal edema.
Medications
Enoxaparin: 30 mg subcutaneous once daily
Metoprolol: 50 mg PO twice a day
Furosemide: 40 mg PO twice daily
Atorvastatin: 20 mg PO once daily


Question 5 of 5

The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?

Correct Answer: D

Rationale: Metoprolol (
D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (
C) treats fluid overload, enoxaparin (
B) prevents thrombosis, and atorvastatin (
A) manages lipids.

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