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Questions 149

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Question 1 of 5

A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?

Correct Answer: C

Rationale: Air embolism requires placing the client in the left lateral decubitus position with the head down to trap air in the right atrium, preventing further embolization. This is the priority action.

Question 2 of 5

An 8-year-old boy is diagnosed with a Wilm's tumor. The nurse would expect what finding on assessment?

Correct Answer: D

Rationale: Wilm’s tumor (nephroblastoma) often presents with an enlarged abdomen due to a palpable renal mass.

Question 3 of 5

A client is admitted to the emergency department with chest pain and is diagnosed with an acute myocardial infarction. The physician orders thrombolytic therapy. The nurse knows that this therapy is contraindicated in which of the following conditions?

Correct Answer: B

Rationale: previous hemorrhagic stroke is an absolute contraindication for thrombolytic therapy due to the risk of bleeding

Question 4 of 5

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

Correct Answer: B

Rationale: Fetal heart tones are a definitive, objective sign of pregnancy, detectable around 20 weeks.

Question 5 of 5

A client is admitted with symptoms of pseudomembranous colitis. Which finding is associated with Clostridium difficile?

Correct Answer: A

Rationale: Clostridium difficile infection causes pseudomembranous colitis, characterized by diarrhea with blood and mucus due to toxin-mediated colonic inflammation.

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