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Questions 158

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Extract:


Question 1 of 5

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

Correct Answer: B

Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.

Question 2 of 5

The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?

Correct Answer: B

Rationale: A WBC of 500/mm3 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people (
B) is critical. Hypothermia (
A) is not a primary concern, soft toothbrush (
C) prevents bleeding, and bleeding (
D) is for thrombocytopenia.

Question 3 of 5

The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?

Correct Answer: A

Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.

Question 4 of 5

The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client?

Correct Answer: C

Rationale: An apple is a healthy, easy-to-eat snack that provides nutrition without excessive sodium (chips), caffeine (cola), or high calories (milkshake), suitable for a manic client needing stability.

Question 5 of 5

Which guidelines would hamper staff learning and compliance?

Question Image

Correct Answer: E, F, G

Rationale: Providing all information in one session (E) can overwhelm staff, reducing retention. Stating changes are mandated (F) may foster resentment, decreasing compliance. Sending a memo about errors (G) may seem punitive, discouraging engagement. In contrast, scientific information (
A), clarification (
B), acknowledging resistance (
C), and diagrams (
D) promote understanding and acceptance.

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