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Questions 164

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Extract:


Question 1 of 5

The nurse is assisting with the care of a client who sustained a cervical spinal cord injury 1 hour ago and has paralysis in all four extremities. Which of the following actions would be a priority for the nurse to take?

Correct Answer: C

Rationale: Respiratory status (
C) is the priority in acute cervical spinal cord injury due to risk of respiratory failure. Repositioning (
A), dysreflexia monitoring (
B), and exercises (
D) are secondary.

Question 2 of 5

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?

Correct Answer: D

Rationale: Nurses cannot dispense medications without a prescription (A,
B). Checking blood pressure (
C) is irrelevant. Referring to a provider (
D) ensures proper evaluation and treatment.

Question 3 of 5

Immediately following a cardiac catheterization, the client asks to go to the toilet. What is the best response by the nurse?

Correct Answer: D

Rationale: Post-catheterization, bed rest is required to prevent bleeding at the insertion site; a bedpan maintains immobility.

Question 4 of 5

The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?

Correct Answer: D

Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.

Question 5 of 5

The nurse is reinforcing skin care guidelines for a client who is receiving external radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching?

Correct Answer: C,D,E

Rationale: Sun protection (
C), gentle washing (
D), and loose clothing (E) are correct for radiation therapy skin care. Ice packs (
A) can damage skin, and baby oil (
B) may irritate or trap radiation.

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