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Questions 149

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Question 1 of 5

The nurse is assessing a newborn 24 hours after birth. Which of the following findings would require further evaluation?

Correct Answer: C

Rationale: milia are normal, but persistent or widespread milia may indicate other issues; other findings are within normal limits for a newborn

Question 2 of 5

A client is receiving a blood transfusion following surgery. In the event of a transfusion reaction, any unused blood should be:

Correct Answer: D

Rationale: Unused blood must be returned to the blood bank for analysis in case of a transfusion reaction.

Question 3 of 5

The physician has prescribed a Becloforte (beclomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:

Correct Answer: B

Rationale: A sore throat may indicate oral candidiasis, a side effect of inhaled corticosteroids like beclomethasone.

Question 4 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.

Question 5 of 5

A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:

Correct Answer: B

Rationale: Autonomic hyperreflexia is often triggered by bladder distension; ensuring a patent catheter addresses the most common cause and can resolve symptoms.

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