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A newborn weighed seven pounds at birth. At six months of age, the infant could be expected to weigh:
- A. 14 pounds
- B. 18 pounds
- C. 25 pounds
- D. 30 pounds
Correct Answer: A
Rationale: Infants typically double their birth weight by 6 months. A 7-pound newborn would weigh approximately 14 pounds at 6 months. The other weights are excessive or unrealistic.
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A client with a history of a ventricular tachycardia is receiving Amiodarone (Cordarone). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Hypokalemia
- D. Pulmonary toxicity
Correct Answer: D
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring monitoring for cough or dyspnea. Hypotension is possible but less specific, and hyperglycemia/hypokalemia are unrelated.
The client is admitted with a diagnosis of molar pregnancy. Which nursing intervention is most appropriate?
- A. Monitor for vaginal bleeding
- B. Prepare for cesarean delivery
- C. Administer tocolytics
- D. Monitor fetal heart tones
Correct Answer: A
Rationale: Molar pregnancy involves abnormal trophoblastic tissue not a viable fetus and can cause significant vaginal bleeding. Monitoring for bleeding is the most appropriate intervention. Cesarean delivery tocolytics and fetal monitoring are not indicated.
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
- A. Avoids eating
- B. Rests in a recumbent position
- C. Eats a meal or snack
- D. Sits upright after eating
Correct Answer: C
Rationale: Duodenal ulcers cause pain relieved by eating due to buffering of gastric acid. Pain worsens when the stomach is empty. Resting or sitting upright does not directly relieve symptoms.
A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?
- A. Partial thromboplastin time
- B. Hemoglobin
- C. Red blood cell (RBC) count
- D. Prothrombin time
Correct Answer: A
Rationale: Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. Hemoglobin is the main component of RBCs. Its main function is to carry O2 from the lungs to the body tissues and to transport CO2 back to the lungs. RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. PT is used to monitor the effects of oral anticoagulants, e.g., coumarin-type anticoagulants.
The nurse is caring for a client with a history of a stroke who has expressive aphasia. The nurse should:
- A. Speak loudly to the client
- B. Use simple, short sentences
- C. Provide a whiteboard for communication
- D. Limit all verbal interactions
Correct Answer: C
Rationale: Expressive aphasia impairs speech production. A whiteboard facilitates communication. Simple sentences help, but writing aids are critical, and loud speech or limiting interaction is unhelpful.