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Questions 158

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Extract:


Question 1 of 5

The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:

Correct Answer: A

Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.

Question 2 of 5

The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?

Correct Answer: A

Rationale: Verifying nasogastric tube placement by aspirating stomach contents (and checking pH) is critical to prevent aspiration. Left-lying position is incorrect, 50% dextrose is inappropriate, and microwaving can cause burns or nutrient degradation.

Question 3 of 5

The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?

Correct Answer: C

Rationale: Fat embolus is most common in long bone fractures, especially the femur, and in young adults. A 21-year-old with a femur fracture (
C) is at highest risk. Fibula (
A), wrist (
B), and arm (
D) fractures have lower risk.

Question 4 of 5

On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:

Correct Answer: B

Rationale: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.

Question 5 of 5

A client with advanced Alzheimer’s disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?

Correct Answer: B

Rationale: Haloperidol, an antipsychotic, commonly causes extrapyramidal side effects like tremors. Cough (
A), diarrhea (
C), and pitting edema (
D) are not typical side effects of haloperidol.

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