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Questions 149

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Question 1 of 5

The nurse is assessing a client with suspected dehydration. Which of the following findings would the nurse expect?

Correct Answer: B

Rationale: dry mucous membranes and tented skin are signs of dehydration due to fluid loss

Question 2 of 5

A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?

Correct Answer: B

Rationale: facilitates swallowing and movement of tube through GI tract

Question 3 of 5

A nurse creates a care plan for a client diagnosed with a cerebellar brain tumor. The correct nursing diagnosis for this client is 'Client at risk for injury related to

Correct Answer: A

Rationale: Cerebellar tumors impair coordination and balance, increasing fall risk, making 'impaired balance' the most relevant diagnosis.

Question 4 of 5

When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:

Correct Answer: A

Rationale: Extracorporeal lithotripsy breaks up kidney stones, leading to cherry-red urine from minor bleeding that clears as healing progresses.

Question 5 of 5

A client who has been taking Coumadin (warfarin) was stabbed in the upper arm. His prothrombin time is over twice the normal amount. The nurse anticipates an order for

Correct Answer: A

Rationale: Elevated prothrombin time indicates excessive anticoagulation. Fresh frozen plasma provides clotting factors to reverse warfarin’s effect and control bleeding.

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