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Question 1 of 5

A client admitted for treatment of bacterial pneumonia has an order for intravenous ampicillin. Which specimen should be obtained prior to administering the medication?

Correct Answer: D

Rationale: A sputum culture and sensitivity test is essential before starting antibiotics like ampicillin to identify the causative organism and ensure appropriate treatment for bacterial pneumonia.

Question 2 of 5

A nurse is assisting the physician with chest tube removal. Which client instruction is appropriate during removal of the tube?

Correct Answer: A

Rationale: Taking a deep breath or humming (Valsalva maneuver) during chest tube removal increases intrathoracic pressure, preventing air entry. Holding breath for two minutes (
B) is excessive, exhaling (
C) risks pneumothorax, and deep breathing (
D) is unsafe.

Question 3 of 5

A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:

Correct Answer: C

Rationale: Regular insulin peaks 2-4 hours after administration, so 12 noon is the expected peak time for a 9:00 AM dose.

Question 4 of 5

A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

Correct Answer: B

Rationale: Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. Increased cardiac output results as fluids shift back to the vascular compartment. Hypertension is the result of hypervolemia.

Question 5 of 5

Which of the following age-related changes affect the vision of the elderly client?

Question Image

Correct Answer: B, C, E

Rationale: Age-related vision changes include decreased lens elasticity (
B), lens discoloration (
C), and enophthalmos (E). Pupil dilation decreases (
A), and eye mobility is unaffected (
D).

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