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Questions 149

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Question 1 of 5

The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?

Correct Answer: D

Rationale: Deflating the cuff during meals allows normal swallowing, reducing aspiration risk, and is maintained for 1 hour post-meal.

Question 2 of 5

During which stage of injury repair does the wound show evidence of erythema and edema, and phagocytosis begins?

Correct Answer: B

Rationale: The inflammation stage (
B) involves erythema, edema, and phagocytosis as the body responds to injury. Other stages (A, C,
D) have different processes.

Question 3 of 5

Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?

Correct Answer: C

Rationale: Immunosuppressants, such as cyclosporine, prevent the immune system from forming antibodies against the transplanted heart.

Question 4 of 5

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

Correct Answer: C

Rationale: Post-tonsillectomy, the risk of bleeding and aspiration is a priority due to the surgical site in the throat.

Question 5 of 5

The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip. If a diagnosis of unilateral dislocation of the right hip is made, which of the following symptoms will the nurse observe?

Correct Answer: B

Rationale: folds and creases will be longer and deeper on affected side

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