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Questions 148

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Question 1 of 5

The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

Correct Answer: B

Rationale: Newborn rashes, such as erythema toxicum, are common and typically resolve spontaneously within weeks, requiring no immediate intervention.

Question 2 of 5

A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

Correct Answer: A

Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.

Question 3 of 5

The nurse is caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms

Question 4 of 5

A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?

Correct Answer: B

Rationale: A moderate amount of clear amniotic fluid is expected after an amniotomy, indicating normal rupture of membranes.

Question 5 of 5

A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which physician prescription would the nurse question?

Correct Answer: A

Rationale: D5W at 200 mL/hr is inappropriate for SIADH, as it can worsen hyponatremia by adding free water. The other options are appropriate for monitoring and treating SIADH.

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