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Questions 148

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Question 1 of 5

The nurse is doing a digital removal of stool for a client with a large fecal impaction resulting from opioid use when the client feels faint, and assessment of vital signs shows a marked decrease in pulse. Which of the following is the most likely reason for the change in pulse rate?

Correct Answer: A

Rationale: Digital stool removal can stimulate the vagus nerve (
A), causing bradycardia and faintness. Shock (
B), bleeding (
C), or anxiety (
D) are less likely.

Question 2 of 5

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

Correct Answer: A

Rationale: Clients with MRSA require contact precautions due to the highly contagious nature of the infection, necessitating a private room to prevent transmission to others.

Question 3 of 5

A client with chronic kidney disease (CKD) is being evaluated by the transplant team. The client's glomerular filtration rate (GFR) is 14 mL/min. This places the client in which stage of CKD?

Correct Answer: B

Rationale: GFR <15 mL/min indicates stage 5 CKD (end-stage renal disease), often requiring dialysis or transplant.

Question 4 of 5

Intra-arterial chemotherapy primarily benefits the client by applying greater concentrations of medication directly to the malignant tumor. An additional benefit of intra-arterial chemotherapy is:

Correct Answer: B

Rationale: Intra-arterial chemotherapy can treat micro-metastases by delivering high drug concentrations to the tumor and surrounding areas.

Question 5 of 5

A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

Correct Answer: C

Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.

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