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Questions 158

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Question 1 of 5

The intensive care unit is full and the emergency room just called to report that a client with suspected carbon monoxide poisoning has arrived. Which clinical manifestation would the nurse expect if carbon monoxide poisoning has occurred?

Correct Answer: C

Rationale: Carbon monoxide binds hemoglobin, forming carboxyhemoglobin, causing cherry red mucous membranes. Pulse oximetry (
A) is unreliable, stridor (
B) suggests obstruction, and carbonaceous particles (
D) indicate smoke inhalation.

Question 2 of 5

A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?

Correct Answer: B

Rationale: High carbohydrates provide high-caloric content to prevent tissue catabolism.

Question 3 of 5

The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?

Question Image

Correct Answer: A, B, C

Rationale: West Nile virus is transmitted by mosquitoes (
A), blood transfusions (
B), and organ transplants (
C). Birds (
D) and horses (E) are hosts but not direct vectors to humans.

Question 4 of 5

A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

Correct Answer: A

Rationale: RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization to Rh-positive blood.

Question 5 of 5

A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?

Correct Answer: C

Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.

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