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Questions 149

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Extract:


Question 1 of 5

The nurse is caring for an infant admitted from the delivery room. Which finding should be reported?

Correct Answer: D

Rationale: Absent femoral pulses suggest coarctation of the aorta, a critical condition.

Question 2 of 5

The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?

Correct Answer: C

Rationale: Oatmeal, apple juice, and dry toast are low in sodium and saturated fat, aligning with a DASH diet for hypertension management.

Question 3 of 5

A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?

Correct Answer: A

Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.

Question 4 of 5

When drawing up a dosage of subcutaneous heparin, how much air should be drawn into the syringe after the correct dosage is obtained?

Correct Answer: C

Rationale: An air lock of 0.2-0.3 mL (
C) is used in subcutaneous heparin injections to ensure the full dose is delivered and to prevent leakage.

Question 5 of 5

A client is 4 hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?

Correct Answer: C

Rationale: Right-sided weakness post-left carotid endarterectomy suggests a neurological deficit, possibly from stroke or hematoma, requiring immediate intervention.

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