The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?

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Question 1 of 5

The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?

Correct Answer: B

Rationale: Metabolic alkalosis is expected after vomiting 9 times in 6 hours. Loss of HCl raises pH, per physiology. Acidosis fits diarrhea, hemoglobin and potassium are secondary. B drives care, making it correct.

Question 2 of 5

The nurse is assessing a 2-day-old infant with a diagnosis of ventricular septal defect (VSD). Which finding should the nurse report immediately to the health care provider?

Correct Answer: D

Rationale: Sweating during feeding needs immediate reporting in VSD. It indicates heart failure from shunt overload, per pathophysiology, requiring urgent care. Murmur is typical, weight gain minor, and HR 160 normal. D signals decompensation, making it critical.

Question 3 of 5

A client with a history of epilepsy is admitted for observation after a seizure. Which precaution should the nurse implement to reduce the risk of injury?

Correct Answer: C

Rationale: Ensuring suction equipment is available reduces injury risk post-seizure. It manages secretions, preventing aspiration, per safety standards. High bed/rails increase fall risk, tongue blades are outdated, and restraints harm dignity. C prioritizes airway, making it best.

Question 4 of 5

A fire breaks out in a trash can in the hallway of a medical unit. Which action should the nurse take first?

Correct Answer: A

Rationale: Pulling the nearest fire alarm is first in a hallway fire. It alerts staff and initiates response (RACE: Rescue, Alarm, Contain, Extinguish), per safety protocol. Extinguishing , evacuating , or closing doors follow. A ensures rapid help, making it priority.

Question 5 of 5

A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

Correct Answer: D

Rationale: Tardive dyskinesia is indicated by lip smacking and teeth grinding in a client on chlorpromazine, a long-term antipsychotic side effect, per psychiatric nursing. Dystonia involves muscle spasms, akathisia is restlessness, and bradykinesia is slowed movement. D requires reporting, potentially adjusting therapy.

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