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Questions 158

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Question 1 of 5

The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:

Correct Answer: D

Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.

Question 2 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 3 of 5

The nurse is caring for a client post-thyroidectomy. Which assessment finding requires immediate intervention?

Correct Answer: B

Rationale: Tingling in the fingers suggests hypocalcemia due to parathyroid gland damage, risking tetany or seizures, requiring immediate intervention. Pain (
A), hoarseness (
C), and mild fever (
D) are expected post-op.

Question 4 of 5

The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?

Correct Answer: A

Rationale: Alendronate should be taken in the morning on an empty stomach, not before bedtime (
A), indicating a need for further teaching. Upright positioning (
B), taking with water (
C), and avoiding food (
D) are correct.

Question 5 of 5

A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be:

Correct Answer: A

Rationale: According to Nägele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 - 3 mo = September 17). (B, C,
D) These answers are incorrect.

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