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Questions 148

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Question 1 of 5

A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.

Correct Answer: A,B,C,F

Rationale: Bowel training includes scheduled toileting (
A), stool softeners (
B), high-fiber diet (
C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (
D) and periodic enemas (E) are not preferred long-term.

Question 2 of 5

The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?

Correct Answer: A

Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.

Question 3 of 5

A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

Correct Answer: C

Rationale: At 4 months, the hepatitis B vaccine is part of the standard immunization schedule, along with DPT and polio vaccines.

Question 4 of 5

An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:

Correct Answer: A

Rationale: Acute laryngotracheobronchitis (croup) is characterized by inspiratory stridor and a harsh, barking cough due to upper airway inflammation and narrowing.

Question 5 of 5

The nurse finds a client smoking marijuana in the hospital and tells her that no smoking or use of drugs is allowed in the facility. The client responds by shouting, 'What business is it of yours? Leave me alone!' Which of the following initial responses is the best for the nurse to use to defuse the situation?

Correct Answer: D

Rationale: A calm, polite request to stop (
D) de-escalates the situation while reinforcing the rule. Other responses (A, B,
C) are confrontational and likely to escalate the client's agitation.

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