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Question 1 of 5

A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to

Correct Answer: C

Rationale: Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.

Question 2 of 5

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply.

Correct Answer: A,B,E

Rationale: Dedicated equipment, hand hygiene, and an isolation gown prevent the spread of vancomycin-resistant enterococcus. A 'No Visitors' sign is unnecessary, and a face mask is not required unless droplet precautions are indicated.

Question 3 of 5

Client self-determination is the primary focus of:

Correct Answer: B

Rationale: Nursing advocacy prioritizes client self-determination, supporting autonomy in healthcare decisions. The other options address different aspects of care or legal protection. Coordinated Care

Question 4 of 5

The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?

Correct Answer: B

Rationale: Spinal column manipulation. The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).

Question 5 of 5

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate?

Correct Answer: D

Rationale: Patching the unaffected eye strengthens the weaker eye in strabismus by forcing its use, a common non-surgical treatment in children. Laser surgery is not typically used, eye drops are irrelevant, and intraocular pressure measurement is for glaucoma, not strabismus.

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