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Questions 157

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Question 1 of 5

An adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also.adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also complains of tingling around the mouth and in the fingers and toes. What should the nurse expect to do initially?

Correct Answer: B

Rationale: Tachypnea and tingling suggest hyperventilation causing respiratory alkalosis; breathing into a paper bag restores CO2 levels, correcting pH.

Question 2 of 5

Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?

Correct Answer: D

Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.

Question 3 of 5

The mother of a 2-month-old child asks the nurse when she should start her son on solids. He is taking about 30 oz of formula per day. How should the nurse respond?

Correct Answer: C

Rationale: Solids are typically introduced between 4-6 months when infants have better head control and digestive maturity, not at 2 months or based on formula volume.

Question 4 of 5

Which of the following snacks would be suitable for a child with gluten-induced enteropathy?

Correct Answer: B

Rationale: Buttered popcorn is gluten-free, making it suitable for a child with celiac disease (gluten-induced enteropathy). The other options contain gluten.

Question 5 of 5

The nurse is teaching a client with a new diagnosis of depression about fluoxetine (Prozac). Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: Suicidal thoughts are a serious fluoxetine side effect, requiring immediate reporting. Options A, C, and D are incorrect.

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