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Question 1 of 5

The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?

Correct Answer: C

Rationale: Fat embolus is most common in long bone fractures, especially the femur, and in young adults. A 21-year-old with a femur fracture (
C) is at highest risk. Fibula (
A), wrist (
B), and arm (
D) fractures have lower risk.

Question 2 of 5

A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:

Correct Answer: A

Rationale: The discomfort of photophobia is alleviated by dimming the lights. Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.

Question 3 of 5

While obtaining information about the client's current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:

Correct Answer: A

Rationale: Ginkgo can increase bleeding risk by inhibiting platelet aggregation, so clients should report signs of bruising or bleeding to their doctor.

Question 4 of 5

The nurse is assessing an adult female client for hypovolemia.

Correct Answer: A

Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (
B) and BUN (
D) are within normal ranges, and urine specific gravity (
C) is normal, not elevated as expected in hypovolemia.

Question 5 of 5

Which finding is expected in the normal newborn?

Correct Answer: B

Rationale: The Moro reflex, a startle response to sudden movement, is a normal finding in newborns, present until about 3-6 months. Epstein pearls are benign but not universal, and the others are abnormal.

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As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:
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