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Questions 164

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Question 1 of 5

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?

Correct Answer: B

Rationale: Asking about recent food intake helps identify unintentional gluten exposure, common in new celiac diagnoses. Assuming 6-8 weeks, immediate referral, or blaming non-compliance may overlook dietary errors or other causes.

Question 2 of 5

The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?

Correct Answer: B

Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.

Question 3 of 5

The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.

Correct Answer: C,D,E

Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.

Question 4 of 5

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly?

Correct Answer: D

Rationale: Ranitidine 150 mg PO at bedtime accurately specifies the dose, route, and timing (qhs = at bedtime). Other options are less precise or redundant (e.g., ‘qd nightly’).

Question 5 of 5

There have been several clients recently who have fallen in the long-term care facility. The nurse would like to reduce the number of falls. Which action is likely to do the most to help prevent falls?

Correct Answer: D

Rationale: Low bed height minimizes fall injury risk, a key prevention strategy. Closer watching, restraints, or call bells are less effective or restrictive.

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