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Questions 158

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Extract:


Question 1 of 5

An expected response to sodium polystyrene sulfonate (Kayexalate) is:

Correct Answer: A

Rationale: Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.

Question 2 of 5

A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?

Correct Answer: D

Rationale: Digoxin's therapeutic level is 0.8-2.0 ng/mL. Digoxin's toxic level is >2.0 ng/mL.

Question 3 of 5

A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:

Correct Answer: C

Rationale: Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.

Question 4 of 5

A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

Correct Answer: A

Rationale: RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization to Rh-positive blood.

Question 5 of 5

The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:

Correct Answer: D

Rationale: The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.

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