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Question 1 of 5

In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

Correct Answer: A

Rationale: Inability to speak is a primary indicator of airway obstruction, as it suggests blocked airflow. Hearing, oxygen saturation, and breath sounds are secondary or less immediate. Safety and Infection Control

Question 2 of 5

Which of the following observations indicates the possibility of a birth injury related to forceps delivery?

Correct Answer: A

Rationale: Asymmetry of the mouth may indicate facial nerve injury, a potential complication of forceps delivery due to pressure on the facial nerve.

Question 3 of 5

An adult is admitted to the hospital with several days of vomiting and diarrhea. Admitting data show RBC level of 4.2 million/mm³ and hematocrit of 54%. What is the best interpretation of these data?

Correct Answer: B

Rationale: Elevated hematocrit (normal: 36-46% for females, 41-53% for males) with normal RBC suggests hemoconcentration from dehydration due to fluid loss from vomiting and diarrhea.

Question 4 of 5

The nurse is giving instructions to a group of women about breast self-examination. Which statement indicates that the client needs more instruction about the procedure?

Correct Answer: D

Rationale: Breast self-exams should continue lifelong, not stop at menopause, as breast cancer risk persists. Other statements reflect correct technique.

Question 5 of 5

The licensed practical nurse is assisting the registered nurse with the triage of four clients. Which client should be cared for first?

Correct Answer: C

Rationale: Circumoral cyanosis and tachypnea indicate severe respiratory distress, requiring immediate care. Lacerations, burns, and nonreactive pupils are serious but less immediately life-threatening.

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