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Questions 164

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Question 1 of 5

A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.

Correct Answer: A,B,D,E

Rationale: Oxygen, occlusive dressing, vital sign monitoring, and provider notification address air embolism risk and hypoxia. High Fowler may worsen air entry; semi-Fowler is preferred.

Question 2 of 5

A client who had a bowel resection 5 days ago says, 'I felt like I split open when I coughed.' The nurse finds the incision edges separated and bowel protruding through the wound. Which of the following actions are appropriate? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Vital signs, sterile saline dressings, provider notification, and low Fowler with flexed knees manage dehiscence and evisceration. Oxycodone is inappropriate during this emergency.

Question 3 of 5

A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:

Correct Answer: B

Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.

Question 4 of 5

The nurse is reviewing new medication prescriptions for a client who has a suspected brain tumor. The client is scheduled for a CT scan of the head with IV iodinated contrast in 24 hours. The nurse should clarify the prescription for

Correct Answer: C

Rationale: Metformin should be held before and after iodinated contrast due to the risk of lactic acidosis if contrast-induced kidney injury occurs. Gabapentin, amlodipine, and phenytoin are safe with contrast.

Question 5 of 5

A 6-month old is brought to the ER by her mother. During the assessment, the nurse finds multiple bruises in different stages of healing and decreased range of motion of the right leg. X-ray confirms a fracture of the right femur. Which statement made by the mother would contribute to a diagnosis of child abuse?

Correct Answer: C

Rationale: The mother's inability to recall any injury event, combined with multiple bruises and a femur fracture, raises suspicion of child abuse due to inconsistent history.

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