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Questions 148

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Extract:


Question 1 of 5

The nurse enters a client's room and finds him lying on the floor. The client says to the nurse, 'I fell because I was trying to go to the bathroom and no one answered my call light.' Which of the following actions by the nurse are correct? Select all that apply.

Correct Answer: A,B,C,D,E

Rationale: All actions are appropriate: assist the client safely, assess for injuries, notify the provider, complete an incident report, and document the fall to ensure proper care and follow-up.

Question 2 of 5

A client with chronic kidney disease (CKD) is being evaluated by the transplant team. The client's glomerular filtration rate (GFR) is 14 mL/min. This places the client in which stage of CKD?

Correct Answer: B

Rationale: GFR <15 mL/min indicates stage 5 CKD (end-stage renal disease), often requiring dialysis or transplant.

Question 3 of 5

A client has a CVP monitor in place. Which would be included in the nursing care plan for this client?

Correct Answer: A

Rationale: CVP readings outside 3-8 cm of water may indicate fluid imbalance or catheter issues, requiring physician notification to prevent complications.

Question 4 of 5

The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

Correct Answer: A

Rationale: A tracheotomy set is kept at the bedside post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma.

Question 5 of 5

Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?

Correct Answer: D

Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.

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