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Questions 149

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Question 1 of 5

The nurse is assessing a client who had a colon resection 2 days ago. The client states, 'I feel like my stitches have burst loose.' Upon further assessment, dehiscence of the wound is noted. The nurse should:

Correct Answer: B

Rationale: Dehiscence requires covering the wound with a sterile, saline-moistened dressing to prevent infection and protect exposed tissues. The other actions are inappropriate or harmful.

Question 2 of 5

The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?

Correct Answer: D

Rationale: Hemarthrosis in hemophilia involves bleeding into joints, causing stiffness, aching, and reduced movement due to joint swelling and pain.

Question 3 of 5

A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?

Correct Answer: D

Rationale: Cor pulmonale, right heart failure from lung disease, causes edema of the lower extremities and distended neck veins due to increased venous pressure.

Question 4 of 5

The doctor has ordered Ampicillin 100 mg every 6 hours IV push for an infant weighing 7 kg. The suggested dose for infants is 25-50 mg/kg/day in equally divided doses. The nurse should:

Correct Answer: D

Rationale: The ordered dose (400 mg/day) exceeds the safe range (175-350 mg/day for a 7 kg infant), requiring the nurse to verify the order with the doctor.

Question 5 of 5

A behavior-modification program has been started for an adolescent with oppositional defiant disorder. Which statement describes the use of behavior modification?

Correct Answer: C

Rationale: Behavior modification often uses token economies and rewards to reinforce positive behaviors, encouraging their repetition in disorders like ODD.

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