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Question 1 of 5

The most important reason to closely assess circumferential burns at least every hour is that they may result in:

Correct Answer: D

Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.

Question 2 of 5

A client with an inguinal hernia asks the nurse why he should have surgery when he has had a hernia for years. The nurse understands that surgery is recommended to:

Correct Answer: A

Rationale: Surgery for an inguinal hernia is recommended to prevent strangulation, where the herniated bowel becomes trapped, leading to ischemia. The other options are not primary concerns.

Question 3 of 5

The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

Correct Answer: B

Rationale: (A,
D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. A potassium level of 3.3 would not be associated with a significant drop in blood pressure.

Question 4 of 5

A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:

Correct Answer: D

Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.

Question 5 of 5

The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?

Correct Answer: C

Rationale: Erythromycin, a macrolide, is safe for penicillin-allergic patients. Cefazolin (
A), Amoxicillin (
B), and Ceftriaxone (
D) are beta-lactams with cross-reactivity risks.

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