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Questions 148

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Question 1 of 5

The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?

Correct Answer: C

Rationale: A red, beefy tongue is a classic sign of pernicious anemia due to vitamin B12 deficiency affecting mucosal tissues.

Question 2 of 5

Ideally, the first dose of what vaccine is given at birth?

Correct Answer: D

Rationale: The hepatitis B vaccine is recommended at birth to prevent perinatal transmission and establish early immunity.

Question 3 of 5

The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first?

Correct Answer: A

Rationale: Repositioning the client is the first step to improve fetal oxygenation if the fetal heart tone strip shows distress, as it is non-invasive and may resolve the issue.

Question 4 of 5

A client with acute alcohol intoxication is being treated for hypomagnesemia. During assessment of the client, the nurse would expect to find:

Correct Answer: D

Rationale: Hypomagnesemia can cause a positive Trousseau's sign, indicating neuromuscular irritability due to low magnesium levels.

Question 5 of 5

The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

Correct Answer: B

Rationale: Flossing can cause gum bleeding, increasing infection and bleeding risks in leukemia clients with low platelet counts.

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