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Questions 164

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Question 1 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 2 of 5

An adult is admitted in severe hypovolemic shock following an auto accident. A transfusion is ordered. What type of blood is given when the client's blood type is not known?

Correct Answer: B

Rationale: O negative is the universal donor, safe for emergency transfusions when the blood type is unknown, minimizing reaction risk.

Question 3 of 5

A client who has been waiting for several hours in the clinic waiting room suddenly begins to shout, 'I need some attention and I need it now!' How should the nurse respond initially?

Correct Answer: C

Rationale: Engaging the client to assess her needs de-escalates agitation and addresses concerns. Silencing, calling security, or explaining delays may escalate tension.

Question 4 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 5 of 5

The nurse prepares a 7-year-old client for an influenza injection. The nurse explains that the client will receive 'medicine under the skin,' and the client is visibly anxious. Which nursing intervention is appropriate?

Correct Answer: D

Rationale: Hiding the needle (
D) reduces anxiety. Counting (
A) may not distract enough, holding arms (
B) can increase fear, and denying pain (
C) is dishonest.

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