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Questions 158

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Question 1 of 5

Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?

Correct Answer: C

Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.

Question 2 of 5

Which behaviors are expected to be observed in the 18-month old?

Question Image

Correct Answer: B, C, E

Rationale: At 18 months, children remove clothes (
B), point to body parts (
C), and kick balls (E). Vocabulary is ~20-50 words (
A), and questioning (
D) emerges later (~2-3 years).

Question 3 of 5

When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:

Correct Answer: C

Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.

Question 4 of 5

A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:

Correct Answer: C

Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.

Question 5 of 5

Which of the following describes a positive Kernig's sign?

Correct Answer: A

Rationale: A positive Kernig’s sign is pain or resistance when flexing the hip and extending the knee often indicating meningeal irritation (e.g. meningitis). The other options describe different symptoms or signs unrelated to Kernig’s.

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