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Questions 149

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Extract:


Question 1 of 5

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?

Correct Answer: B

Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.

Question 2 of 5

The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:

Correct Answer: C

Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.

Question 3 of 5

Which play activity is best suited to the gross motor skills of the toddler?

Correct Answer: B

Rationale: Playing with a ball encourages gross motor skills like kicking and throwing, suitable for a toddler's developmental stage.

Question 4 of 5

The nurse is teaching a client with a new diagnosis of migraine headaches about trigger avoidance. Which of the following should the client avoid?

Correct Answer: B

Rationale: aged cheeses contain tyramine, a common migraine trigger

Question 5 of 5

A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?

Correct Answer: A

Rationale: Increased jaundice and prolonged prothrombin time indicate liver dysfunction, consistent with acute liver transplant rejection.

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