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Questions 164

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Extract:

Laboratory reference ranges
INR
0.8-1.1


Question 1 of 5

The nurse receives report on 4 clients. Which of the following clients should the nurse see first?

Correct Answer: A

Rationale: Discomfort at an IV vancomycin site suggests possible infiltration or phlebitis, requiring immediate assessment to prevent tissue damage. INR of 1.9 is subtherapeutic but less urgent, itching/nausea are expected morphine side effects, and tubing changed 48 hours ago is within standard protocol.

Extract:


Question 2 of 5

Magnetic resonance imaging has been ordered for a client. Which factor should the nurse report to the physician?

Correct Answer: B

Rationale: A pacemaker is a contraindication for MRI due to magnetic interference, requiring immediate physician notification to ensure safety.

Question 3 of 5

The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?

Correct Answer: D

Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.

Question 4 of 5

A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:

Correct Answer: B

Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.

Question 5 of 5

The nurse is to administer a tuberculin skin test. At what angle should the needle be inserted?

Correct Answer: A

Rationale: A 10-degree angle ensures intradermal injection for a tuberculin skin test, creating a wheal for accurate reading.

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