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Questions 164

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Question 1 of 5

A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

Correct Answer: D

Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.

Question 2 of 5

A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?

Correct Answer: A

Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.

Question 3 of 5

The nurse is collecting data from a client with Bell’s palsy. Which of the following findings would the nurse expect to observe? Select all that apply.

Correct Answer: A,D,E

Rationale: Bell’s palsy causes unilateral facial weakness, leading to asymmetrical smiling, loss of forehead/brow movement, and reduced lacrimation. Frequent blinking is unlikely due to impaired muscle control, and shock-like pain is typical of trigeminal neuralgia.

Question 4 of 5

At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to

Correct Answer: A

Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

Question 5 of 5

The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?

Correct Answer: C

Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.

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