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Extract:

Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%


Question 1 of 5

The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?

Correct Answer: B

Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (
B). Levothyroxine (
A), warming (
C), and lab review (
D) are secondary.

Extract:


Question 2 of 5

The nurse is caring for a frail elderly client in her home. Which behavior, if observed or reported, should the nurse report to the supervisor for further evaluation of possible abuse?

Correct Answer: B

Rationale: Leaving a frail client alone for hours poses neglect risk, warranting abuse evaluation. Guardianship, brown spots, or yelling are less definitive without context.

Question 3 of 5

The nurse is providing teaching to the parents of a 1-year-old who was just prescribed a 10-day course of amoxicillin for acute otitis media. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.

Correct Answer: C, E

Rationale: Returning if no improvement (
C) and hearing screening (E) are appropriate. Decongestants (
A) are not recommended, loose stools (
B) do not warrant stopping, and stopping early (
D) risks resistance.

Question 4 of 5

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.

Correct Answer: A, B, D

Rationale: Date of birth (
A), first and last name (
B), and medical record number (
D) are reliable identifiers. Health care provider (
C) and room number (E) are not specific to the client.

Question 5 of 5

A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?

Correct Answer: B

Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.

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