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Questions 158

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Extract:


Question 1 of 5

The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

Correct Answer: C

Rationale: An O2 saturation of 68% indicates severe hypoxemia requiring immediate oxygen administration (e.g. via mask) to restore oxygenation. Elevating the head rechecking later or assessing heart rate are secondary to correcting hypoxia.

Question 2 of 5

The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?

Correct Answer: C

Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.

Question 3 of 5

The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:

Correct Answer: D

Rationale: The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.

Question 4 of 5

A client with a history of a burn injury is receiving Hydrotherapy. The nurse should:

Correct Answer: C

Rationale: Monitoring water temperature during hydrotherapy prevents further burn injury, ensuring it’s lukewarm. Hot water, petroleum products, and plastic wrap are contraindicated.

Question 5 of 5

Which situation would be reportable to the state board of nursing?

Correct Answer: B

Rationale: An incorrect narcotic count for three days suggests potential diversion or mismanagement of controlled substances a serious issue reportable to the state board of nursing. The other situations are administrative or safety issues but not typically reportable to the board.

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