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Questions 158

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Question 1 of 5

A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:

Correct Answer: B

Rationale: Pulmonary contusions from blunt chest trauma cause alveolar edema and hemorrhage, leading to bloody sputum, hypoxemia, and patchy infiltrates on x-ray.

Question 2 of 5

The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client's treatment, the nurse should:

Correct Answer: D

Rationale: Nephrotic syndrome causes edema due to protein loss, requiring fluid management. Offering additional fluids is inappropriate unless prescribed, as it may worsen edema. Visitors, diet, and dialysis depend on specific orders.

Question 3 of 5

The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:

Correct Answer: C

Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.

Question 4 of 5

A diagnosis of hepatitis C is confirmed by a male client's physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?

Correct Answer: C

Rationale: Hepatitis C has an incubation period of 2-26 weeks. It has a high potential for chronic liver disease, an insidious onset, and no effective vaccine, unlike hepatitis B.

Question 5 of 5

When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:

Correct Answer: C

Rationale: Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. Regular formulas contain lactose, which can increase diarrhea.

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