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Questions 148

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Question 1 of 5

The nurse is caring for an adult who had an appendectomy 6 hours ago. Which intervention would the nurse expect to perform to promote rest and sleep? Select all that apply.

Correct Answer: B, C, D

Rationale: Ambien, a cool room, and fresh linens promote rest. A heavy meal may disrupt sleep post-surgery.

Question 2 of 5

The nurse is assisting a client who is to undergo a thoracentesis. Which of the following is the optimal position for the procedure?

Correct Answer: D

Rationale: The upright position leaning forward (
D) maximizes lung expansion and access to pleural fluid during thoracentesis.

Question 3 of 5

The nurse is working on the cardiac unit with a client scheduled to receive digitalis. The nurse understands that which finding is a contraindication for this medication? Select all that apply.

Correct Answer: A,D,E

Rationale: AV block, sick sinus syndrome, and Wolff-Parkinson-White syndrome are contraindications for digitalis due to the risk of worsening conduction abnormalities. Atrial flutter and fibrillation are indications.

Question 4 of 5

Which assignment should not be performed by the nursing assistant?

Correct Answer: D

Rationale: Administering an enema is an invasive procedure requiring clinical judgment, which is beyond the scope of a nursing assistant's responsibilities.

Question 5 of 5

A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct Answer: B

Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical finding in bacterial meningitis in infants.

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