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Questions 164

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Extract:


Question 1 of 5

The nurse has delegated care of a client who is very hard of hearing to an unlicensed person. Which of the following would be the least helpful information to give to the unlicensed person to better facilitate communications with the client?

Correct Answer: C

Rationale: Anticipating and finishing statements risks miscommunication and frustration, least helpful for effective communication with a hearing-impaired client.

Question 2 of 5

The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.

Correct Answer: B,C,D

Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.

Question 3 of 5

The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Phenytoin binds to enteral feedings, reducing absorption. Holding feedings for 1 hour before and after administration ensures efficacy. Tube placement should be verified before, not after, administration. Blood pressure and pancreatic enzymes are unrelated.

Question 4 of 5

The practical nurse and the charge nurse work together to assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat argumentative cellulitis. Which of the 4 room assignments is the best option for this client?

Correct Answer: A

Rationale: The postoperative client in Room 1 is stable and awaiting discharge, posing the least risk of complications or infection to the client with cellulitis. Other roommates have conditions (dementia, embolism, immunosuppression) that could complicate care or increase infection risk.

Question 5 of 5

A client with schizophrenia is ready to begin participating in therapeutic activities. The nurse should suggest that the client:

Correct Answer: C

Rationale: Art activities with a small group provide a structured, low-stress environment suitable for a client with schizophrenia, promoting social interaction without overwhelming them.

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