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Questions 163

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Extract:


Question 1 of 5

The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?

Correct Answer: C

Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.

Question 2 of 5

A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor?

Correct Answer: B

Rationale: Ejecting the air bubble in an enoxaparin syringe is incorrect, as the bubble ensures complete dose delivery and prevents leakage. Other actions (A, C,
D) are correct for subcutaneous administration.

Question 3 of 5

A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client?

Correct Answer: B

Rationale: New-onset confusion with disorientation, difficulty focusing, memory loss, and lethargy post-ventilation and lorazepam suggests delirium , often seen in ICU patients due to medication withdrawal or critical illness. Amnesia , dementia , and psychosis have different presentations.

Question 4 of 5

Which client condition is concerning and requires further nursing observation and intervention? Select all that apply.

Correct Answer: B,D,E

Rationale: Concerning conditions include: spinal cord injury with hypotension suggesting neurogenic shock; black stool and tachycardia indicating possible GI bleeding; and inconsolable neonate with tachycardia suggesting distress. Asthma with hypertension and stable pulse on metoprolol are less urgent.

Extract:

Laboratory reference ranges
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)

Female: 12.0–16.0 g/dL
(120–160 g/L)
WBC
5000–10,000/mm³
(5–10 × 10⁹/L)


Question 5 of 5

The nurse is collecting data from a client with acute diverticulitis. Which of the following findings would be essential to follow up?

Correct Answer: A

Rationale: Pain progressing to the left upper quadrant in diverticulitis is concerning for complications like perforation or abscess, requiring follow-up. Mild anemia and flexed positioning are common, and a moderately elevated WBC is expected in acute inflammation.

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