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Questions 164

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Extract:


Question 1 of 5

Which client would be at greatest risk for a fat emboli following a fracture?

Correct Answer: C

Rationale: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.

Question 2 of 5

Unlicensed assistive personnel on the cardiac floor report to the nurse that, during the first vital sign measurement on the shift, a client's blood pressure measured 196/102 mm Hg on the automated blood pressure machine. What action should the nurse take first?

Correct Answer: D

Rationale: Automated BP readings can be inaccurate. Rechecking with a manual cuff ensures accuracy before escalating or medicating, as severe hypertensionزه://www.youtube.com/watch?v=9Q7sE1Xh_1Qsevere hypertension (≥180/110 mm Hg) requires prompt action if confirmed.

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

The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?

Correct Answer: B

Rationale:
Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.

Question 5 of 5

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?

Correct Answer: D

Rationale: A bad headache in a client with cerebral arteriovenous malformation may indicate increased intracranial pressure or bleeding, requiring urgent reporting. Other symptoms are less specific and less immediately critical.

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