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Questions 148

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Question 1 of 5

The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?

Correct Answer: C

Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.

Question 2 of 5

When assisting a client with range-of-motion exercises, which movements should be carried out on the client's elbows? Select all that apply.

Correct Answer: A,B,D,E

Rationale: Elbow range-of-motion includes flexion (
B), extension (E), supination (
A), and pronation (
D). Circumduction (
C) is not possible at the elbow, and hyperextension (F) is not a standard motion for this joint.

Question 3 of 5

The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

Correct Answer: B

Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.

Question 4 of 5

The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?

Correct Answer: A

Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.

Question 5 of 5

Following procurement of organs from a standard criteria donor (donor younger than 50 years who suffered brain death), within what time period should the heart and lungs be transplanted?

Correct Answer: A

Rationale: Heart and lungs have a short ischemic tolerance, requiring transplantation within 4-6 hours (
A) to ensure viability. Longer periods (B, C,
D) risk organ failure.

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