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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

A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?

Correct Answer: A

Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.

Question 3 of 5

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply.

Correct Answer: A,C,E

Rationale: SIADH causes water retention, leading to decreased serum osmolality , high urine specific gravity , and low serum sodium due to dilution. High osmolality and increased urine output are opposite findings.

Question 4 of 5

A client with Alzheimer disease is admitted to the hospital. The client's adult child says to the nurse, 'I really want to continue caring for my mother at home, but she has become agitated and restless at night. I am awake most of the night, feel exhausted, and do not know what to do.' What is the best response by the nurse?

Correct Answer: B

Rationale: Referring to a social worker provides access to resources like respite care or home support, addressing the caregiver's exhaustion. Limiting naps or medication may help but are narrow, and suggesting a facility dismisses the caregiver's wishes.

Question 5 of 5

An adult comes to the clinic with complaints of frequency and burning on urination. The nurse expects that what test will be ordered for the client?

Correct Answer: A

Rationale: Frequency and burning suggest urinary tract infection; a clean catch urine culture identifies the causative organism and antibiotic sensitivity. CBC, cystoscopy, or straining are less immediate.

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