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Questions 149

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Extract:


Question 1 of 5

Upon entering the client's room the nurse discovers a dose of amoxicillin at the bedside. Which of the following should the nurse do?

Correct Answer: A

Rationale: Documenting in the medical record and filing an incident report address the medication error and ensure follow-up for patient safety.

Question 2 of 5

A client is 4 hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?

Correct Answer: C

Rationale: Right-sided weakness post-left carotid endarterectomy suggests a neurological deficit, possibly from stroke or hematoma, requiring immediate intervention.

Question 3 of 5

The nurse is performing a neurological assessment on a client. She asks the client to smile, close both eyes, and frown. Which cranial nerve (CN) is the nurse testing?

Correct Answer: B

Rationale: Cranial nerve VII (facial) controls facial movements like smiling, frowning, and closing eyes.

Question 4 of 5

The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?

Correct Answer: B

Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.

Question 5 of 5

The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

Correct Answer: D

Rationale: A white blood cell count of 450 indicates severe immunosuppression, so the fruit should be removed to prevent infection from potential contaminants.

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