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Questions 164

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Question 1 of 5

An 8-year old is admitted with drooling, muffled phonation and a temperature of 102.6°. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:

Correct Answer: B

Rationale: Drooling, muffled phonation, and fever suggest epiglottitis, a medical emergency requiring immediate intervention due to the risk of airway obstruction.

Question 2 of 5

A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?

Correct Answer: B

Rationale: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.

Question 3 of 5

An adult is admitted in severe hypovolemic shock following an auto accident. A transfusion is ordered. What type of blood is given when the client's blood type is not known?

Correct Answer: B

Rationale: O negative is the universal donor, safe for emergency transfusions when the blood type is unknown, minimizing reaction risk.

Question 4 of 5

When reviewing the chart of a client with long standing lung disease, the nurse should pay close attention to the results of which pulmonary function test?

Correct Answer: C

Rationale: The FEV1/FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answers A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.

Question 5 of 5

The nurse in the mental health unit is talking with several clients during group therapy. A client becomes angry and throws a fire extinguisher at another client. Which of the following actions would be a priority for the nurse to take?

Correct Answer: C

Rationale: Ensuring safety by escorting others away (
C) is the priority. Rapid response (
A) may be premature, approaching the client (
B) risks escalation, and informing of consequences (
D) is secondary.

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