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Questions 164

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Question 1 of 5

In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?

Correct Answer: C

Rationale: Check the client for bladder distention and the client's urinary catheter for kinks. These are findings of autonomic dysreflexia, typically initiated by a noxious stimulus below the level of injury such as a full bladder.

Question 2 of 5

A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?

Correct Answer: C

Rationale: Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Letting tap water run for several minutes will diminish the lead contamination.

Question 3 of 5

One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 μmol/L). Which action by the health care provider does the nurse anticipate?

Correct Answer: B

Rationale: A phenytoin level of 32 mcg/mL is toxic (therapeutic range: 10-20 mcg/mL), so the dose should be decreased (
B). Continuing (
A) or increasing (
C) the dose risks toxicity. Repeating the level (
D) delays intervention.

Question 4 of 5

The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?

Correct Answer: A

Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (
A). Warming dialysate (
B), pain medication (
C), and positioning (
D) do not address the infection.

Question 5 of 5

Following cardiac surgery, a client's urine output for the last hour is 20 mL. The nurse understands that this indicates which of the following?

Correct Answer: B

Rationale: Low urine output (20 mL/hour) post-cardiac surgery suggests insufficient cardiac output, impairing renal perfusion. Hyperkalemia, inadequate fluids, or diuresis are less likely causes without additional signs.

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