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Questions 164

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Extract:

Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)


Question 1 of 5

The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?

Correct Answer: B

Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.

Extract:


Question 2 of 5

The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?

Correct Answer: B

Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.

Question 3 of 5

The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.

Correct Answer: B,C,D

Rationale: Hirschsprung disease causes intestinal obstruction, leading to a distended abdomen, failure to pass meconium, and nonbilious vomiting. Bright red bleeding suggests other causes (e.g., fissure). Feeding refusal is less specific.

Question 4 of 5

A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?

Correct Answer: B

Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.

Question 5 of 5

The nurse is planning care for a group of senior citizens. The nurse should plan activities that promote achievement of which developmental task?

Correct Answer: D

Rationale: Ego integrity, accepting one's life as meaningful, is the developmental task for seniors per Erikson's theory. Identity, intimacy, and generativity apply to younger stages.

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