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Questions 163

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Question 1 of 5

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

Correct Answer: C

Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.

Question 2 of 5

The client has been receiving garamycin 65 mg IVPB every 8 hours for the past 6 days. Which lab result indicates an adverse reaction to the medication?

Correct Answer: D

Rationale: Garamycin (gentamicin) is an aminoglycoside antibiotic that can cause nephrotoxicity. A serum creatinine level of 2.0 mg/dL is elevated (normal range is approximately 0.6-1.2 mg/dL), indicating potential kidney damage, an adverse reaction. Answers A, B, and C represent normal or unrelated lab values.

Question 3 of 5

The nurse is discussing mammogram screening with a family. No one in the family has had a mammogram. The mother is 52, there are four daughters, ages 10, 15, 21, and 34, and the grandmother is 75. Which of the following women should receive a mammogram? Select all that apply.

Correct Answer: D,E,F

Rationale: Women aged 40 and older, or earlier with risk factors, should have mammograms. The 34-year-old, 52-year-old, and 75-year-old women meet screening age criteria.

Question 4 of 5

A client receiving total parenteral nutrition reports nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?

Correct Answer: A

Rationale: Nausea, abdominal pain, and thirst in a TPN client suggest hyperglycemia, so checking blood glucose is the best action. Vital signs , reporting , or slowing infusion are secondary without glucose confirmation.

Question 5 of 5

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention?

Correct Answer: C

Rationale: During a lumbar puncture for an infant, holding the child in a flexed position with head and knees tucked and back rounded ensures proper spinal alignment for safe needle insertion. Oxygen is not routinely needed, cleaning is typically done by the provider, and vital sign monitoring is important but not the primary intervention.

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