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Questions 148

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Extract:


Question 1 of 5

A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?

Correct Answer: D

Rationale: Pain (
D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (
A), vital signs (
B), and oxygen saturation (
C) are secondary.

Question 2 of 5

A 13-year-old female has been diagnosed with celiac disease. Which of the following dinner trays would be acceptable?

Correct Answer: A

Rationale: Celiac disease requires a gluten-free diet. Option A (chicken, carrots, potato) is gluten-free, while others contain gluten (wheat bread, spaghetti, flour tortillas).

Question 3 of 5

A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

Correct Answer: A

Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.

Question 4 of 5

The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?

Correct Answer: D

Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.

Question 5 of 5

A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?

Correct Answer: B

Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.

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