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Questions 148

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Question 1 of 5

The nurse is calculating the Apgar score for a newborn. Findings are as follows: Heart rate: 110, Respiratory effort: good cry, Muscle tone: some flexion of extremities, Reflex irritability: grimace, Color: completely pink. What is the Apgar score for this neonate?

Correct Answer: C

Rationale: Heart rate 110 (2), good cry (2), some flexion (1), grimace (1), pink (2) = 9.

Question 2 of 5

The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?

Correct Answer: A

Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.

Question 3 of 5

A client diagnosed with tuberculosis asks the nurse when he can return to work. The nurse should tell the client that:

Correct Answer: A

Rationale: Three negative sputum cultures indicate the client is no longer contagious, allowing safe return to work after tuberculosis treatment.

Question 4 of 5

A patient is rushed to the emergency room after being found unconscious at home. His blood pressure is 70/35. The nurse anticipates an order for what medication?

Correct Answer: E

Rationale: For severe hypotension (BP 70/35), vasopressors like norepinephrine or dopamine are typically ordered to restore perfusion, but none of the listed options are vasopressors. The question may be flawed.

Question 5 of 5

A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:

Correct Answer: D

Rationale: Raw fruits and vegetables may harbor pathogens, increasing infection risk in immunocompromised clients with HIV.

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