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Questions 158

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Extract:


Question 1 of 5

A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

Correct Answer: A

Rationale: The child no longer has normal white blood cells and is extremely susceptible to infection, necessitating protective isolation.

Question 2 of 5

A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?

Correct Answer: D

Rationale: (A, B,
C) These answers are all correct; however, maintenance of airway is the top priority. Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.

Question 3 of 5

A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

Correct Answer: A

Rationale: RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization to Rh-positive blood.

Question 4 of 5

A client with a history of chronic venous insufficiency is admitted with complaints of leg ulcers. The nurse should give priority to:

Correct Answer: A

Rationale: Wound care is critical for leg ulcers in chronic venous insufficiency to promote healing and prevent infection.

Question 5 of 5

The nurse is caring for a client with diabetes mellitus. Which instruction should be given to the client?

Correct Answer: D

Rationale: Numbness and tingling in the feet and toes may indicate diabetic neuropathy a serious complication requiring prompt reporting. Avoiding stairs reducing sodium or daily weighing are not specific to diabetes management unless indicated.

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