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Questions 176

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Question 1 of 5

A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?

Correct Answer: D

Rationale: Wheezing and hives (
D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (
A), flushing/pruritus (
B), and low blood pressure (
C) are less immediately life-threatening.

Question 2 of 5

In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?

Correct Answer: C

Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.

Question 3 of 5

A client reports that someone is in the room and trying to kill him. The nurse's best response is:

Correct Answer: B

Rationale: It is important to acknowledge the client's fear. The other responses deny the client's perceptions.

Question 4 of 5

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?

Correct Answer: A

Rationale: Contraction duration of 95 seconds (
A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (
B), intensity (
C), and resting tone (
D) are within normal limits.

Question 5 of 5

A client with Addison's disease will most likely exhibit which symptom?

Correct Answer: B

Rationale: A bronze pigmentation is a sign of Addison's disease. Answers A, C, and D are symptoms of Cushing's syndrome, making them incorrect.

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