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Questions 149

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Question 1 of 5

The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:

Correct Answer: B

Rationale: A blood alcohol concentration of 460 mg/dL (0.46%) is life-threatening, with respiratory depression being the priority due to its potential to cause death.

Question 2 of 5

A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?

Correct Answer: D

Rationale: Elevated serum amylase levels, particularly above 3 times the normal range, confirm acute pancreatitis due to pancreatic enzyme release.

Question 3 of 5

Which nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?

Correct Answer: A

Rationale: A firm fundus 3 finger widths below the umbilicus by day 3 postpartum indicates normal uterine involution, as the uterus shrinks progressively after delivery.

Question 4 of 5

The nurse is assessing a client with suspected dehydration. Which of the following findings would the nurse expect?

Correct Answer: B

Rationale: dry mucous membranes and tented skin are signs of dehydration due to fluid loss

Question 5 of 5

The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:

Correct Answer: A

Rationale: The correct sequence is inspection, auscultation, palpation to avoid altering bowel sounds or causing discomfort during the exam.

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