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Questions 148

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Extract:


Question 1 of 5

The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?

Correct Answer: A

Rationale: contact precautions required for diapered or incontinent clients

Question 2 of 5

The nurse is caring for a client who is 12 weeks pregnant and presented with the following symptoms: mild uterine cramping with spotting of blood. The cervical os is closed upon examination. How should the nurse chart the findings?

Correct Answer: D

Rationale: Mild cramping, spotting, and a closed cervical os at 12 weeks indicate a threatened miscarriage, where the pregnancy may still continue.

Question 3 of 5

A client is to be discharged on warfarin (Coumadin®) therapy, and the nurse is teaching the client about the medication. Which of the following statements by the client indicates that the client's education has been effective? Select all that apply.

Correct Answer: A,C,D

Rationale: Soft toothbrush (
A), swimming (
C), and Medical Alert bracelet (
D) reduce bleeding risk and ensure safety. Black stools (
B) indicate bleeding, and avoiding all leafy greens (E) is excessive.

Question 4 of 5

A client has orders for placing a small-bore nasoenteric tube. Which finding in the health history would prompt the nurse to notify the prescriber before placing tube?

Correct Answer: B

Rationale: A basilar skull fracture is a contraindication for nasoenteric tube placement due to the risk of intracranial insertion. Other conditions are not absolute contraindications.

Question 5 of 5

A client has a chest tube in place with a three-chamber chest drainage system. The nurse notes continuous bubbling in the water seal chamber. This indicates which of the following?

Correct Answer: C

Rationale: Continuous bubbling in the water seal chamber indicates a system air leak (
C), such as a loose connection or hole in the tubing. A pneumothorax (
A) may cause intermittent bubbling, adequate suction (
B) is indicated by bubbling in the suction chamber, and incorrect tube positioning (
D) would not typically cause continuous bubbling.

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