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Questions 148

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Question 1 of 5

A nurse is caring for an 84-year-old client who is malnourished. The nurse is concerned about all of the following complications of malnutrition EXCEPT

Correct Answer: C

Rationale: Malnutrition increases fall risk, impairs wound healing, and raises infection risk due to weakened immunity. Chronic heart failure is not directly caused by malnutrition.

Question 2 of 5

A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should

Correct Answer: D

Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.

Question 3 of 5

The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?

Correct Answer: B

Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.

Question 4 of 5

The client delivered a 9-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:

Correct Answer: C

Rationale: Sitz baths relieve episiotomy pain by promoting circulation and healing.

Question 5 of 5

The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:

Correct Answer: C

Rationale: Lactulose reduces ammonia levels to prevent hepatic encephalopathy.

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