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Questions 149

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Question 1 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.

Question 2 of 5

The nurse answers a call to the unit, which turns out to be a bomb threat. Which actions by the nurse are correct? Select all that apply.

Correct Answer: B, D

Rationale: Following protocol and alerting authorities ensure safety and proper response, while dismissing the threat or evacuating without orders is unsafe.

Question 3 of 5

Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?

Correct Answer: A

Rationale: indication that the client is approaching delirium tremens, which can be avoided with additional sedation

Question 4 of 5

A 51-year-old client received a kidney transplant. Which of the following signs and symptoms indicates possible rejection of the kidney? Select all that apply.

Correct Answer: B,C,D

Rationale: Kidney rejection causes hypertension (
B), fluid retention (weight gain,
C), and graft pain (
D). Decreased urine output (not increased) and elevated creatinine (not decreased) are typical.

Question 5 of 5

A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?

Correct Answer: B

Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.

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