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Questions 148

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Extract:


Question 1 of 5

The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:

Correct Answer: B

Rationale: Hypotension and unresponsiveness suggest hypovolemia or shock, so increasing the normal saline infusion is the initial action to restore volume.

Question 2 of 5

A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?

Correct Answer: A

Rationale: Nutrasweet (aspartame) contains phenylalanine, which must be avoided in phenylketonuria, indicating a need for further teaching.

Question 3 of 5

A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.

Correct Answer: A,B,E

Rationale: Phenytoin's long-term effects include gingival hypertrophy (
A), hirsutism (
B), and anemia (E). Facial hypertrophy (
C) and dementia (
D) are not associated with phenytoin.

Question 4 of 5

A client is admitted for an CAT scan. The nurse should question the client regarding:

Correct Answer: A

Rationale: Pregnancy is a contraindication for a CAT scan due to radiation risks to the fetus.

Question 5 of 5

Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?

Correct Answer: D

Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.

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