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Questions 158

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Question 1 of 5

The nurse is caring for a client with a history of a mastectomy who is receiving Tamoxifen (Nolvadex). The nurse should teach the client to:

Correct Answer: A

Rationale: Tamoxifen increases the risk of endometrial cancer, so vaginal bleeding must be reported immediately. Sun exposure, caffeine, and fluid intake are not primary concerns.

Question 2 of 5

The client at 28 weeks gestation is admitted with a diagnosis of preterm labor. The physician orders a non-stress test. The nurse should explain to the client that this test is used to:

Correct Answer: C

Rationale: A non-stress test (NST) evaluates fetal well-being by monitoring fetal heart rate accelerations in response to movement. It does not assess lung maturity contractions or maternal hypertension.

Question 3 of 5

The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:

Correct Answer: B

Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.

Question 4 of 5

A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:

Correct Answer: D

Rationale: Keeping the leg straight for 8-12 hours minimizes bleeding risk at the arterial puncture site after coronary arteriography.

Question 5 of 5

The physician prescribes regular insulin, five units subcutaneous. Regular insulin begins to exert an effect:

Correct Answer: C

Rationale: Regular insulin (short-acting) has an onset of 30–60 minutes when given subcutaneously, peaking at 2–3 hours. This allows time for absorption and glucose-lowering effects.

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