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Questions 148

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Extract:


Question 1 of 5

The nurse is reviewing medication orders for his clients. Which order would necessitate contacting the health care provider?

Correct Answer: B

Rationale: Promethazine is contraindicated in children with Reye’s syndrome due to the risk of worsening neurological symptoms. Other orders are appropriate.

Question 2 of 5

The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?

Correct Answer: E

Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.

Question 3 of 5

A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

Correct Answer: A

Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.

Question 4 of 5

A nurse is caring for an 84-year-old client who is malnourished. The nurse is concerned about all of the following complications of malnutrition EXCEPT

Correct Answer: C

Rationale: Malnutrition increases fall risk, impairs wound healing, and raises infection risk due to weakened immunity. Chronic heart failure is not directly caused by malnutrition.

Question 5 of 5

A client with obsessive compulsive personality disorder annoys his coworkers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:

Correct Answer: D

Rationale: Setting a time schedule helps the client manage perfectionistic tendencies by structuring tasks, reducing preoccupation with trivial details.

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