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Questions 164

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Extract:


Question 1 of 5

The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?

Correct Answer: C

Rationale: Introducing new foods 5-7 days apart (
C) prevents allergic reactions by identifying triggers, making it the priority. Cost (
A), finger foods (
B), and cow's milk (D, not recommended before 12 months) are secondary.

Question 2 of 5

A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?

Correct Answer: B

Rationale: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.

Question 3 of 5

The nurse is screening clients for those at risk of developing nephrolithiasis. Which of the following factors would increase a client's risk of developing nephrolithiasis?

Correct Answer: A,B,E

Rationale: Gout (
A), dehydration (
B), and hyperparathyroidism (E) increase nephrolithiasis risk due to uric acid, concentrated urine, and calcium imbalances, respectively. Hypokalemia (
C) and thrombocytopenia (
D) are unrelated.

Extract:

Vital signs
Blood pressure 105/60 mm Hg
Heart rate 80/min
Respirations 22/min
SpO2 90% on room air
Nurse notes
The client has a history of coronary artery disease and peripheral vascular disease. Nursing assessment reveals crackles in middle & lower lung fields, moderate jugular venous distension, and 3+ pedal edema.
Medications
Enoxaparin: 30 mg subcutaneous once daily
Metoprolol: 50 mg PO twice a day
Furosemide: 40 mg PO twice daily
Atorvastatin: 20 mg PO once daily


Question 4 of 5

The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?

Correct Answer: D

Rationale: Metoprolol (
D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (
C) treats fluid overload, enoxaparin (
B) prevents thrombosis, and atorvastatin (
A) manages lipids.

Extract:


Question 5 of 5

A client using a diaphragm should be instructed to:

Correct Answer: A

Rationale: Leaving a diaphragm in place longer than 8 hours increases infection risk. Resizing is needed for significant weight changes (e.g., 10+ pounds) or post-surgery, not minor changes.

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