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Questions 148

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Question 1 of 5

The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first?

Correct Answer: A

Rationale: Repositioning the client is the first step to improve fetal oxygenation if the fetal heart tone strip shows distress, as it is non-invasive and may resolve the issue.

Question 2 of 5

The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?

Correct Answer: C

Rationale: A red, beefy tongue is a classic sign of pernicious anemia due to vitamin B12 deficiency affecting mucosal tissues.

Question 3 of 5

A client with Graves' disease is brought to the ER with a suspected thyroid storm. The nurse expects to see what signs and symptoms?

Correct Answer: E

Rationale: Thyroid storm presents with fever, tachycardia, agitation, and sweating. None of the options fully match, but A (irregular heartbeat, vomiting) is closest, though seizures and jaundice are less typical.

Question 4 of 5

A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is having the desired effect?

Correct Answer: D

Rationale: Increased reticulocyte count indicates effective B12 therapy for anemia.

Question 5 of 5

The nurse is assessing a client for tactile fremitus. Which client would most likely exhibit a decrease in tactile fremitus? A client with:

Correct Answer: A

Rationale: Emphysema causes air trapping and hyperinflation, reducing tactile fremitus due to decreased transmission of vocal vibrations through the lungs.

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