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Which of these findings would the nurse more closely associate with anemia in a 10 month-old infant?
- A. hemoglobin level of 12 g/dL
- B. pale mucosa of the eyelids and lips
- C. hypoactivity
- D. a heart rate between 80 and 130
Correct Answer: B
Rationale: pale mucosa of the eyelids and lips. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.
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A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: Lower the oxygen rate. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis. Unless corrected, it can lead to the client's death.
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
- A. Change in libido, breast enlargement
- B. Sore throat, fever
- C. Abdominal pain, nausea, diarrhea
- D. Dyspnea, nasal congestion
Correct Answer: B
Rationale: A sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine).
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
- A. such fantasies can gratify unconscious wishes or prepare for anticipated future events
- B. detaching or dissociating in this way postpones painful feelings
- C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership
- D. isolating the feelings in this way reduces conflict within the client and with others
Correct Answer: A
Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.
The nurse is preparing to care for the client diagnosed with tuberculosis who has been coughing up blood. Which illustration best shows the PPE that the nurse should plan to wear?
- A. ppe_1.PNG
- B. ppe_2.PNG
- C. ppe_3.PNG
- D. ppe_4.PNG
Correct Answer: D
Rationale: D: N95 respirator for airborne precautions and a face shield for blood exposure are appropriate. Other options lack adequate respiratory or splash protection.
The nurse educator is focusing on the prevention of infection. Place an X on the illustration that displays the best measure to prevent infection when caring for clients on a nursing unit?
- A. infection_1.PNG
- B. infection_2.PNG
- C. infection_3.PNG
- D. infection_4.PNG
- E. infection_5.PNG
Correct Answer: A
Rationale: A: Hand hygiene is the most effective measure to prevent infection transmission. Other measures like isolation or gloves are situational, but hand washing is universally critical.