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A client is being admitted with a diagnosis of possible pancreatitis. Which of the following is the best support for this diagnosis?
- A. Pain is in the left upper quadrant of the abdomen
- B. Client reports steatorrhea for the last 3 days
- C. A serum amylase level of 366 U/L
- D. Assessed diminished bowel sounds
Correct Answer: C
Rationale: The client's amylase level is elevated above the normal level of 200 U/L. This measurement is the most accurate indicator of pancreatitis and the most objective and specific. The answers in A, B, and D are also clinical manifestations of pancreatitis, but are not as specific as the laboratory value, so they are incorrect choices.
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A client with Anemia has been prescribed liquid iron. Which would the nurse expect to be included in the teaching plan?
- A. Take the medication through a straw.
- B. Administer this drug mixed with coffee.
- C. The drug causes the urine to turn black.
- D. The drug must be stored in the refrigerator.
Correct Answer: A
Rationale: Liquid iron should be administered through a straw to prevent dental staining. Answers B, C, and D are not correct instructions for taking liquid iron, so they are incorrect.
A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?
- A. Keep the infant NPO for two hours before the treatment.
- B. Ask the mother to stay away from the infant during the treatment.
- C. Monitor the client's pulse rate very carefully.
- D. Cover the baby's eyes during the treatment.
Correct Answer: D
Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.
A nurse is preparing to administer an intramuscular injection. Which of the following sites is most appropriate for an adult patient?
- A. Deltoid
- B. Vastus lateralis
- C. Dorsogluteal
- D. Ventrogluteal sites
Correct Answer: D
Rationale: The ventrogluteal site is safest for IM injections in adults, minimizing nerve or vessel damage. Deltoid and vastus lateralis are alternatives but less preferred, and dorsogluteal is avoided due to sciatic nerve risk.
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Lying down after eating slows gastric emptying, reducing dumping syndrome symptoms. Sitting up prevents acid reflux in GERD. The other combinations are incorrect for these conditions. Basic Care and Comfort
A nurse is administering blood to a patient who has a low hemoglobin count.
The patient asks how long the RBC last in the body? The correct response is:
- A. The life span of RBC is 45 days.
- B. The life span of RBC is 60 days.
- C. The life span of RBC is 90 days.
- D. The life span of RBC is 120 days.
Correct Answer: D
Rationale: Red blood cells have a lifespan of approximately 120 days.