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A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?
- A. Cold and dry skin.
- B. Facial puffiness and periorbital edema.
- C. Hematocrit of 30% (0.30 volume fraction).
- D. Further decline in the level of consciousness.
Correct Answer: D
Rationale: A further decline in consciousness indicates worsening hypothyroidism or myxedema coma, requiring urgent intervention.
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A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 100 mL/hr
- B. 125 mL/hr
- C. 150 mL/hr
- D. 175 mL/hr
Correct Answer: B
Rationale: Dividing 1000 mL by 8 hours yields 125 mL/hr, the correct infusion rate.
The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
- A. Superficial partial-thickness.
- B. Full-thickness.
- C. Deep partial-thickness.
- D. Deep full-thickness.
Correct Answer: B
Rationale: A painless, brown/yellow, swollen burn indicates full-thickness damage, involving the epidermis and dermis.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Crohn's disease with colectomy.
- C. History of nephrotic syndrome.
- D. Type 2 diabetes mellitus.
Correct Answer: B
Rationale: Crohn's disease with colectomy creates peritoneal adhesions, making peritoneal dialysis unsuitable.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.
Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?
- A. Lean beef, salads, and baked potatoes.
- B. Potatoes, low-fat breads, and applesauce.
- C. Oatmeal, raisins, and fruit with skin.
- D. Chicken, rice, and wheat products.
Correct Answer: C
Rationale: Oatmeal, raisins, and fruit with skin are high in fiber, which supports gut health and reduces the risk of colorectal cancer.