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Questions 158

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Extract:


Question 1 of 5

The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:

Correct Answer: B

Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.

Question 2 of 5

Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?

Correct Answer: D

Rationale: A recurrent fetal heart rate of 90-100 bpm at the end of contractions (late decelerations) is ominous indicating fetal hypoxia from uteroplacental insufficiency. Normal heart rate (120-130) variability and accelerations are reassuring findings.

Question 3 of 5

Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:

Correct Answer: D

Rationale: S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. Pulse pressure differences of >20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate-sized cuffs. Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.

Question 4 of 5

The nurse is preparing to administer a dose of penicillin to a client with a streptococcal infection. Which assessment is most important before administration?

Correct Answer: A

Rationale: Penicillin has a high risk of allergic reactions, including anaphylaxis. Assessing allergy history is critical before administration. Vital signs are monitored but are less specific to penicillin risks.

Question 5 of 5

The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?

Correct Answer: A

Rationale:
Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron.
Tomatoes provide vitamin C, which aids iron absorption, but lack significant iron content.

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