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Questions 227

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Extract:

After a craniotomy for the removal of hematoma sustained in a fall, the patient is returned to the recovery room.


Question 1 of 5

The nurse places the child in a semi-fowler's position to

Correct Answer: A

Rationale: This position utilizes gravity to drain fluid from the head and prevent fluid accumulation, reducing the risk of increased intracranial pressure.

Extract:


Question 2 of 5

A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

Correct Answer: A

Rationale: A blood sugar of 50 mg/dL indicates hypoglycemia (normal 70–110 mg/dL), causing symptoms like confusion, cold, clammy skin, and tachycardia (pulse 110). Hyperglycemia (
B) causes hot, dry skin and Kussmaul respirations, normal findings (
C) are unlikely, and fluid overload (
D) is unrelated.

Extract:

After a craniotomy for the removal of hematoma sustained in a fall, the patient is returned to the recovery room.


Question 3 of 5

The nurse places the child in a semi-fowler's position to

Correct Answer: A

Rationale: This position utilizes gravity to drain fluid from the head and prevent fluid accumulation, reducing the risk of increased intracranial pressure.

Extract:


Question 4 of 5

Upon entering a client's room, the nurse sees and smells smoke and flames. What is the best initial nursing action?

Correct Answer: B

Rationale: Moving the client out of the room prioritizes patient safety, following the RACE (Rescue, Alarm, Contain, Extinguish) fire protocol.

Question 5 of 5

The nurse is teaching a client with a new diagnosis of hypertension about medication adherence. Which of the following statements by the client indicates a need for further teaching?

Correct Answer: B

Rationale: Stopping antihypertensive medication when blood pressure normalizes risks rebound hypertension, indicating a need for further teaching. Daily timing (
A), reporting side effects (
C), and continued use (
D) reflect proper understanding.

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