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Questions 164

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Question 1 of 5

The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to

Correct Answer: A

Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.

Question 2 of 5

The nurse is talking with the parent of a 2-year-old client who has a sunburn across the back and shoulders. Which of the following statements by the parent would indicate a correct understanding of sunburn care? Select all that apply.

Correct Answer: A,C,D

Rationale: Extra fluids prevent dehydration, cool compresses soothe skin, and outdoor play with protection (sunscreen, clothing) is safe. Aspirin is avoided in children due to Reye's syndrome risk. Hydrocortisone isn't standard for sunburn; aloe or moisturizers are preferred.

Question 3 of 5

The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?

Correct Answer: B

Rationale:
Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.

Question 4 of 5

A client with tuberculosis has an order for Rifadin (rifampin). What vitamin is usually given with rifampin?

Correct Answer: B

Rationale: Pyridoxine (vitamin B6) is given with rifampin to prevent peripheral neuropathy, a side effect. Other vitamins are not typically associated with rifampin therapy.

Question 5 of 5

The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: A

Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.

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