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Questions 149

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Question 1 of 5

A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?

Correct Answer: A

Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.

Question 2 of 5

The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.

Correct Answer: A, B, C

Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.

Question 3 of 5

A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.

Correct Answer: A,C,D

Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.

Question 4 of 5

A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?

Correct Answer: B

Rationale: Demadex, a loop diuretic, causes potassium loss, increasing the risk of hypokalemia, unlike potassium-sparing diuretics like Aldactone.

Question 5 of 5

A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?

Correct Answer: C

Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.

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