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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 total knee replacement. The client complains of pain and swelling. The nurse should:

Correct Answer: A

Rationale: Ice reduces pain and swelling post-total knee replacement by decreasing inflammation. Elevation is helpful, aspirin requires an order, and notification is needed if symptoms persist.

Question 2 of 5

The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:

Correct Answer: B

Rationale: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.

Question 3 of 5

The best size cathlon for administration of a blood transfusion to a six-year-old is:

Correct Answer: D

Rationale: A 20-gauge catheter is appropriate for blood transfusions in a six-year-old balancing adequate flow rate and minimal vessel trauma. Smaller gauges (22) may be too small and larger gauges (18 19) are more invasive than necessary.

Question 4 of 5

The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

Correct Answer: C

Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (
A), wheezing (
B), and pain/rales (
D) are concerning but less urgent.

Question 5 of 5

When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

Correct Answer: A

Rationale:
Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).

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