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Question 1 of 5

A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is

Correct Answer: D

Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

Question 2 of 5

The nurse has reinforced teaching with the parent of a pediatric client with newly diagnosed hemophilia A. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.

Correct Answer: C,D,E

Rationale: Medical identification ensures prompt treatment in emergencies. Noncontact sports like swimming are safe. Aspirin increases bleeding risk and should be avoided. Ice packs are beneficial for injuries to reduce swelling, and diet doesn't require high-fat/protein for hemophilia management.

Question 3 of 5

Written instructions to pregnant women include instructions to perform Kegel exercises. One of the women asks the nurse why these exercises are important. The nurse should reply that the purpose of these exercises is to:

Correct Answer: B

Rationale: Kegel exercises strengthen pelvic floor muscles, supporting bladder control and aiding postpartum recovery, directly addressing their purpose.

Question 4 of 5

Unlicensed assistive personnel on the cardiac floor report to the nurse that, during the first vital sign measurement on the shift, a client's blood pressure measured 196/102 mm Hg on the automated blood pressure machine. What action should the nurse take first?

Correct Answer: D

Rationale: Automated BP readings can be inaccurate. Rechecking with a manual cuff ensures accuracy before escalating or medicating, as severe hypertensionزه://www.youtube.com/watch?v=9Q7sE1Xh_1Qsevere hypertension (≥180/110 mm Hg) requires prompt action if confirmed.

Question 5 of 5

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply.

Correct Answer: C,D

Rationale: Small, frequent meals reduce stomach acid reflux, and avoiding fatty foods decreases acid production. Dairy can neutralize acid, large fluid intake with meals distends the stomach, and lying down post-meal worsens reflux.

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