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Questions 158

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Question 1 of 5

A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:

Correct Answer: B

Rationale: Supplemental O2 should be administered before and after suctioning to reduce hypoxia.

Question 2 of 5

The client is admitted with a diagnosis of acute leukemia. Which nursing intervention is the priority?

Correct Answer: B

Rationale: Acute leukemia causes immunosuppression, making infection prevention (e.g., hand hygiene, protective isolation) the priority to avoid life-threatening complications. Pain, glucose, and diet are secondary.

Question 3 of 5

An elderly patient has been taking 80 mg of furosemide (Lasix) bid. The nurse notes that the patient's most recent potassium level is 2.5mEq/L. The nurse should:

Correct Answer: D

Rationale: A potassium level of 2.5 mEq/L indicates hypokalemia, a serious side effect of furosemide, a potassium-wasting diuretic. The nurse should withhold the medication and notify the physician to address the electrolyte imbalance.

Question 4 of 5

Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?

Correct Answer: C

Rationale: This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. This practice is one correct way of burping an infant.

Question 5 of 5

The nurse is caring for a client with a history of a pulmonary embolism who is receiving Lovenox (enoxaparin). The nurse should monitor the client for:

Correct Answer: A

Rationale: Enoxaparin, a low-molecular-weight heparin, increases bleeding risk, requiring monitoring for signs like bruising or hematuria. Hypertension, tachypnea, and fever are not primary concerns.

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