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During physical assessment of a patient’s abdomen, the nurse should perform the four basic techniques in the following order:
a. Auscultation, palpation, inspection, percussion b. Inspection, auscultation, percussion, palpation c. Inspection, auscultation, palpation, percussion
Mr. Santibañez is scheduled for an upper GI series. Which intervention should the nurse perform after the procedure?
a. testing stool for occult blood b. auscultating the abdomen for bowel sounds c. assessing gag reflex d. forcing fluids
A patient who has undergone a Billroth II operation may prevent dumping syndrome by: a. drinking water with meals b. remaining upright after meals c. avoiding bending over d. lying down after meals
what position can be assumed during episodes of acute pancreatitis? a. knees flexed towards abdomen b. supine with legs extended c. trendelenburg d. lithotomy
Data or information obtained from the assessment of a patient is primarily used by the nurse to: a. ascertain the patient’s response to health problems b. assist in constructing taxonomy of nursing interventions c. determine the effectiveness of the doctor’s order d. identify the patient’s disease process.
Answer: C It is most important to identify the etiology of a nursing diagnosis because doing so: a. describes the patient’s health problem or response in a few words c. assist in organizing nursing care of patients with similar diagnosis b. gives direction to the required nursing intervention d. indicates the presence of a particular health problem in a .
collaborative d. professional . codependent c.Answer: B When the nurse and respiratory therapist determine that 1 hour prior to each meal is the ideal time for the patient’s respiratory therapy. which type of nursing intervention is the nurse performing? a. independent b.
Which role is defined as the protection of human or legal rights and securing of quality care for each patient? a. communicator d. leader . counselor b.Answer: A The nurse performs many roles in the practice of nursing. advocator c.
becomes vital in developing nursing knowledge c. forms the basis for the professional code of ethics of nursing d.Answer: A Critical thinking is essential to a nurse because it: a. is needed to successfully pass the board exams . is constantly used for solving problems and making sound judgments b.
Answer: A A patient is evaluated in the doctor’s office with complaints of nonproductive cough with low grade fever. low pitched sound d. high-pitched sound c. The nurse is auscultating for which of the commonly heard sounds? a. medium pitched sound b. The nurse auscultatesthe patient’s lungs with the flat disc diaphragm of the stethoscope. moderately pitched sound .
foreseeable crisis . Health Threat c. Mang Julio’s health condition can be classified as: a.Answer: B Family Santos lives in one of the squatter’s area in Manila. Mang Julio is a 48 yo carpenter who has been suffering from TB for the past few months and Aling Rosing washes clothes for their neighbors to augment their family income.
15 gtts/min c. 21 gtts/min b.Answer: C The physician orders 1000 ml of PNSS to run over 12 hours to an adult patient. 17 gtts/min d. What is the flow rate in drops per minute? a. 23 gtts/min .
13 ml d. How much medication will you prepare to administer the correct dose/ a.000 units per ml.3 ml c. 1.Answer: A The physician orders an IV dose of 400. 1.5 ml b. The label on the 10 ml ampulesent from the pharmacy reads Penicillin G 300. 10 ml .000 units of PenG.
headache. itching or rash c. unusual sleepiness or fatigue d.Answer: B The nurse is preparing to transfuse a unit of packed RBC to an assigned patient. nausea and vomiting . mild discomfort at the catheter site b. chills. The nurse teaches the client that is most important to report which of the following signs immediately: a.
resistance and exhaustion . achieve balance between its internal and external environment d. mobilize its responses of alarm.Answer: C Homeostasis is a concept which refers to the body’s attempt to: a. maintain a balance between parasympathetic and sympathetic nervous system c. satisfy the basic physiologic needs before progressing to higher level of needs b.
depression b. isolation d. shame c. The nurse helps the client work towards the task of developing integrity and helping him overcome feelings of: a. inferiority .Answer: D A nurse asks a 10 yochild to assist with his dressings on burns he has sustained.
the client is more likely to discuss her concerns if she senses the nurse is sexually experienced b. he needs to have a broad base of experience to be helpful to the client c. his nervousness about such discussion could result in .Answer: C A nurse who provides sexual counseling should first become comfortable with his own sexuality because: a.
review and define the nurse-patient relationship c. it is best for the nurse to: a. indicate that intimate relationship between patient and nurse is . tell the patient that this behavior is offensive and leaves the room d.Answer: C When a patient makes sexual advances to a nurse caring for him. report the incident to the attending physician b.
leave the room with the promise to return when his behavior is acceptable . request the client to cover himself c. ignore the inappropriate behavior b.Answer: A What action by the nurse is most appropriate if the client exposes his genitals? a. cover the client d.
Can you discuss some of your sexual . Are you worried you will not be able to perform well sexually with your wife when you go home? c.Answer: B Which question posed by the nurse to the client who has just suffered from a heart attack is most likely encourage him to discuss sexual concerns? a. many men have concerns about their sexual functioning. Some men who have suffered a heart attack must limit their sexual activity for a while. Are you concerned about how this will affect your life? d. after a heart attack. What are some of your concerns? b.
within the client’s reach at the right side .Answer: B A nursing assistant is assigned to care for a client with hemiparesis of the right arm and leg. the nurse instructs the nursing assistant to place personal articles: a. within the client’s reach on the left side b. With regards to morning care.
b.Answer: C An older client with cystitis has an indwelling urinary catheter. A nursing assistant is caring for the client and the nurse would intervene if the nursing assistant. used soap and water to cleansed the perineal area. . kept the drainage bag below the level of the bladder c. let the drainage tubing hang on the bed. used the drainage tubing port to obtain urine samples d. a.
using a gloved finger to open the client’s mouth c.Answer: D The registered nurse is supervising a nursing assistant performing mouth care on an unconscious client. turning the client’s head to one side b. placing an emesis basin under the client’s mouth . The nurse would intervene if the nurse notices the nursing assistant doing which among the following? a.
scrub clothes and plastic aprons b. using gloves and a gown only when giving direct care to the client c. wearing protective garb.Answer: A The nurse manager is observing a new nursing graduate caring fro a burn client in protective isolation. performing strict hand washing techniques . gloves. including a mask. shoe covers. cap. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of the protective isolation technique? a.
needs to assign 4 clients and has a registered nurse. planning assignments for clients on a medical surgical unit. a licensed practical (vocational) nurse and two nursing assistants on a nursing team.A n sw e r: Answer: B B A registered nurse in charge. Which of the following patients would the nurse most appropriately assign the licensed practical (vocational) nurse? A. a client with an abdominal wound requiring wound irrigations and dressing . an older client requiring assistance with a bed bath and frequent ambulation C. the client who requires a 24 hour urine collection. a client on a mechanical ventilator requiring frequent assessment and suctioning D. B.
c. . d. right hand and placing the cane in front of the right foot.A n sw e r: C A client with right sided hemiparesis needs to learn how to use a cane. left hand and 6 inches lateral to the left foot. left hand and placing the cane in front of the left foot. right hand and 6 inches lateral to the right foot. The nurse plans to teach the client to position the cane by holding it with the a. b.
the need to have spare crutches and tips available b. not to see someone else’s crutches d. . a. that crutch tips will not slip even when wet c. The client needs reinforcement of information by the nurse if the client states.Answer: B A client has already been given by the nurse instructions about crutch safety. that crutch tips should be inspected periodically for wear.
5/8 inch needle inserted at a 45 degree angle with the bevel side down. 20 gauge. 1 inch needle inserted almost parallel to the skin with the bevel side up d. intradermally. c.1 ml. 1 inch needle inserted at a 30 degree angle with the bevel side . 0. 26 gauge. 2 gage. by using a tuberculin syringe with a a.Answer: A A nurse administers the ordered PPD. 26 gauge. 5/8 inch needle inserted almost parallel to the skin with the bevel side up b.
Answer: C A nurse is preparing to give a bed bath to an immobilized TB client. gown. The nurse should plan to wear which of the following items when performing this care? a. protective eyewear and particulate respirator c. protective eyewear and . and particulate respirator b. gloves. gown. surgical mask and gloves d.
placing the client in a supine or lying position.Answer: C A client with a respiratory disorder and is at risk for atelectasis was prescribed with an incentive Spirometer. . b. position client in semi-flowers position instruct t inhale shallow breaths from the mouthpiece. have position in sitting position. Which of the following indicates the proper use of incentive spirometer? a. have the client enclosed lips in the mouthpiece . d. let the client release breath as soon a possible after inspiration. instruct the client seal lips around mouthpiece and inhale slowly and deeply until desired volume is attained. and inhale slowly and deeply until desired volume is reached. c.
decrease TPN rate to 50 ml/hr d. c. hang 1 L 0. continue current infusion rate orders fro TPN. the client is expected to begin taking solid food today. A nurse anticipates that which of the following orders regarding the TPN solution will accompany the diet order? a. discontinue the TPN b.Answer: Being weaned from TPN. The ongoing solution rate is has been 100 ml/hour.9% normal saline .
b. d. the nurse notes that the infusion is 1 hour behind. adjust the infusion rate to catch up over the next hour. increase the infusion rate to catch up over the next 2 hours. .While monitoring the client’s status of fat emulsion infusion. adjust the infusion rate to run wide open until the solution is back on time. ensure that the fat emulsion infusion rate is infusing at the prescribed rate c. Which of the following actions by the nurse is most appropriate? a.
c. . wash the receiver regularly to maintain good amplification of sounds d. reaching the receiver with oil before and after used. adjusting the volume to the maximum hearing level to prevent feedback squeaking b.A nurse is reviewing instructions to a patient about to be discharged with a hearing aid which of following instruction will the nurse provide? a. turning off the hearing aid and remove the battery when not in use.
the stoma is pink color ad slightly edematous b.A nurse is evaluating the colostomy of a one day post operative client who had an abdominal perineal resection for bowel tumor. the stool is liquid in immediate post operative period c. Which of the following assessment findings indicates that the colostomy is not in good condition? a. output becomes more solid several days after the procedure d. stoma gradually turns into purple in color .
A 35 year old is scheduled for colonoscopy. In planning for the post procedural care. return of bowel sounds. a. fever d. signs of rectal perforation c. . the nurse recognizes that the most important to monitor after the procedure is. presence of abdominal pain b.
Answer: C How would the nurse check the proper placement of NGT tube before feeding? a. auscultating for gurgling sound when air is injected into the tube d. no coiling of tube viewed in the . aspirating fro gastric contents and checking if with low pH. immersing the tip of the tube in water c. b.
place the palm of your hand (or hands) lightly over the thorax. ask him to lie down so that you can palpate his knee. to assess the patient fro this sign. c. use the pads of your.What Is the correct description of the proper assessment of tactile fremitus? a. Next. or ulcerations. Place your hand firmly on the client’s chest. Press our fingers over the ribs and any scars. . b. to palpate the front and back of the thorax. fingers. d. lumps. to displace the excess fluid. lesions. without touching his back with your fingers. hyperextend the middle finger of your left hand if you’re right handed. Use the tip of the middle finger of your dominant hand to tap on the middle finger of your other hand just below the distal joint. loud enough to produce palpable vibrations.Answer: B . Ask the patient to repeat the phrase “ninety-nine”. lightly placing you open palms on both sides of the patient’s back. Then palpate the front of the chest using the same hand positions. then give the medial side of this knee 2-4 firm strokes.
and date d. How is this error best corrected? a.Answer: C The nurses data on a chart and discovers she has written on the wrong chart. b. obliterate the error so it ill not e confusing. write out the wrong information and write over it. . draw a straight lie through the error. c. recopy the page with the error so chart will be neat. initial.
c.Answer: B What is the best nursing action when the client gives information which is pertinent to care? a. share this information with everyone in the unit b. share this information with those needing to know for planning care. share this information only with . write the information in the chart only d.
b. the nurse finds the informed consent form already signed. the client states that his wife read it and said it was okay. the client can give a return verbal explanation of the informed consent document.Answer: C What client response would the nurse identify as an indication that the client understands the informed consent document? a. . c. the client states that the physician has explained the procedure to him. d.
. What is the best nursing action? a.Answer: B While caring for an 8 year old child with a broken wrist the nurse notices red. not worry about the incident as there is no actual proof of abuse to the child. leaning away. raised streaks on the child’s back. b. disregard suspicions and care for the immediate need of the child. c. from the father as he approaches the child. d. The child’s father enters the room and the child becomes quiet and distant. chart that the child was probably beaten by the father. notify the supervisor to report possible child abuse.
Answer: C What is the nurse’s best approach to avoid claims of negligence? a. b. c. . adhere to all hospital policies. keeping a current license. d. competent practice of nursing. a strong and binding contract for services.
a strong and binding contract for services. b. keeping a current license. c. competent practice of nursing. d. .What is the nurse’s best approach to avoid claims of negligence? a. adhere to all hospital policies.
c. Which judgment error would be considered most damaging? a. withholding information from the attorney d. being argumentative while on the witness stand . arguing with the plaintiff over the case. making illegal changes in the chart b.
supervisor and physician. b. tell the physician to give the medication himself. What is the best response? a. .Answer: D The physician asks the nurse to give a client a medication that the nurse knows the client is allergic to. When the nurse tries to point this out to the physician. offer a meeting between the nurse. d. c. agree to give the medication but not initial the dose. the physician threatens to tell the nurse’s supervisor. walk away and ignore him.
c.Answer: B What is the key component in a quality assurance program? a. d. patient satisfaction questionnaire. case management for continuity of care. b. determine criteria to meet the standard. . an acuity system for client satisfaction.
Answer: C The nurse is preparing to administer an intramuscular injection to an infant who is 8 months old. dorsogluteal c. vastus lateralis d. Which muscle would be the most appropriate injection site? a. ventrogluteal . biceps b.
. The drip factor for the tubing is 10gtt/cc. b. 33gtt/min. how many drops per minute would you run the IV? a. 50gtt/min. 25gtt/min. d. c.Answer: The physician orders an IV piggyback of Cefotan 1gm in 100cc D5W to run over 30 minutes. 12gtt/mon.
the elderly client metabolizes and excretes the drugs differently from younger and more active client. multiple simultaneous drugs can be dangerous. b. c. .Answer: A What should the nurse take into consideration when giving medication to an elderly client? a. medication has an effect on the respiratory system of the elderly.
.Answer: C What is the first step the nurse should do to ensure that the right medication is being given to a client? a. d. check the client’s ID band b. check the order with the medication administration sheet. c. check the expiration date on the medication. read the information insert for direction as to correct administration.
The nurse pours a dose of medication. record the dose as taken to keep the count correct. charge for the dose because the dose must be paid for c. record the medication as “not taken” and waste the poured dose. d. pour the medication back into the container. What is the most appropriate nursing action? a. b. and then finds the client no longer needs the dose. .
expiration date of the drug. . c. chart to see if the drug was ordered. client’s name b. What should she check first? a.The nurse is verifying whether or not to give a medication to a client. route of delivery d.
What is the rationale for this action? a. The nurse draws up an extra 0. c. decrease the possibility of injection . b. While drawing up the medication.Answer: C A client is to get Demerol 75mg IM for pain. seal the injection site with an air bubble. d. give the site enough space in case the client is a bleeder.3cc of air in the syringe. clear the drug from the needle and seal the site.
pronation . a. extension c. flexion b. external rotation d. A movement of joint that occurs in the hinge joint except.
develop interaction between nurse and client b. facilitate the body’s reparative process by manipulating client’s environment d. care for and help client’s retain total self care c.Answer: C The goal of nursing according to Florence Ninghtngale is to: a. reduce stress so that the client can move more easily through .
Hildegard Peplau c. This model was popularizes by: a. nursing care becomes necessary when the client is unable to fulfill biological. In this model. psychological. Dorothea Orem b. developmental or social needs. Virginia Henderson . Faye Abdellah d.Answer: A One example of nursing model is the self care deficit theory.
½ full b. 2/3 full .Which of the following is the right amount of water in filling the hot water bag? a. ¼ full c. 1/3 full d.
sitz c. finished d. alcohol b.Answer: B A bath where a patient’s buttocks. thighs and lower trunk are immersed in water with varying temperature is called? a. tepid sponge .
Vitamin D d. Which of the following vitamins is responsible for the normal development of RBC? a. Vitamin E . folic acid b. Vitamin C c.
Review of Systems . Lopez and then documents her: a. The nurse carefully listens to Mrs. Health History b. Mrs. Lopez is seeking health for respiratory problem. Chief complaint c. Medical Diagnosis d.
the assessment being made is: a. d. “who are you?”. general health history c. psychosocial history b. level of consciousness . general physical exam. When the nurse asks the patient.
When the hand is rotated upward.Answer: B The nurse is describing the patient’s position in the chart. supination . extension d. rotation b. The position is documented as? a. pronation c.
the range of motion is called? a.Answer: C When the extremity is moved away from the midline. adduction . extension c. abduction d. flexion b.
palpation b. auscultation . inspection c. percussion d.Answer: D The assessment skill that the nurse most commonly implements to assess the heart is: a.
6 pm . 4 am c.Answer: C Body temperature can vary through out the day At what point during the 24 hour cycle is the highest? a. 9 pm d. 1 am b.
The nurse should take his temperature by the following method: a. groin c. oral b. rectal d. axillary .Answer: D A patient who has had hemorrhoids surgery has chills.
pulse deficit b. thready pulse c. normal pulse . When the radial pulse is different than the apical pulses.Answer: A The nurse is charting pulse rates. pulse fibrillation d. it is documented as: a.
120/70 b. 160/100 . 140/90 c. 120/90 d. What is his blood pressure? a.You noted the difference between Mang Andres systolic and diastolic blood pressure is 60 mmHg.
The student is correct if he says: a. small blood pressure cuff may cause brachial nerve damage b. small blood pressure cuff may result to false low measurement . small blood pressure cuff may result to false high measurement d. small blood pressure may lead to skin breakdown c.Answer: C A clinical instructor asks a student regarding the effect of using a small blood pressure cuff to an adult obese patient.
. amount of residual urine in the bladder c.Answer: B The purpose of straight catheterization immediately after voiding is to determine the: a. urine specific gravity d. development of a urethral infection b. total amount of urine voided.
urinary tract infection . the nurse is aware that the greatest risk of urinary catheterization is: a. bladder irrigation b. bladder puncture d.Answer: D in planning care. bladder swelling c.
The best position for administering cleansing enema to facilitate evacuation is: a. supine d. semi-fowler’s b. knee chest . left lateral c.
the leading cause of death is: a.Answer: D In teaching child safety to the family. the nurse emphasizes safety tips at home. poisoning c. aspirations . For children less than one year. drowning b. child abuse d.
comfort and ease b.Answer: B Before attempting to lift the patient. stability and balance c. the nurse considers the major purpose of maintaining the wide base of support is to provide: a. strength and mobility d. stronger muscle group .
Answer: D To provide adequate base of support. -1 inches apart b. the feet should be positioned. 6-8 inches apart d. a. 4-6 inches apart c. 10-12 inches apart .
evaluate the patient’s socioeconomic status b. assess the area for venous stasis/ contractures .Performing a backrub on a patient after a bed bath gives the nurse the opportunity to: a. evaluate the patient’s response to bed bath c.
For the nurse to identify a person in pain it means: a. c. pain is whatever the patient says it is.Answer: B Pain is subjective assessment. pain depends as the physical source b. pain must be physical to justify medications. d. objective data are essential in .
nutrition . elimination d. love c. the greatest priority of which is: a. a nurse must remember Maslow’s hierarchy of physiologic needs.Answer: A In prioritizing nursing care services to patients in the ward. oxygen b.
poor living conditions b. obesity and renal disease d. drug abuse .Answer: C Which is the following risk factor is associated with genetic and physiologic factors? a. poor personal hygiene c.
Which of the following is not a purpose of cleansing bath and skin care? a. to provide exercise d. to promote comfort c. to reduce local inflammation b. to stimulate circulation .
Which of the following is not a guideline when providing a client with any type of bath? a. provide depending on the needs of the client b. maintain safety c. promote client independence d. provide privacy
Which of the following client groups have the least risk for sensory alterations during hospitalization? a. elderly clients b. clients in ICU c. ambulatory patients d. bedridden patients
A physician prescribed acetaminophen gr x (10 grains) as necessary every 4 hours for pain for a client in a long term care facility. How many milligrams of acetaminophen should the nurse give? a. 10mg b. 325 mg c. 650 mg d. 1000 mg
“Are you immune to tetanus?” c. He comes to the emergency department with a deep laceration on the bottom of his foot. “Was the glass dirty?” b. “When did you have your last tetanus shot?” d. “How many Diptheria – pertusis – tetanus shots did you received as a child?” .Answer: C A man stepped on a piece of sharp glass while waling barefoot. Which of the following questions is the most important for the nurse to ask? a.
on the initial nurse patient relationship d. at the beginning of every shift b. at the beginning and end of each shift . in the terminating phase of the nurse patient relationship c.Answer: D Assessment phase of the nursing process is completed: a.
discard the first stool of the day and use the next three stools. d. b. avoid eating red meat before testing. To ensure valid test results.Answer: A The physician orders three stool specimens for occult blood from a client who complains of blood-streaked stools and 10 pounds weight loss in 1 month. the nurse should instruct the client to: a. take three specimen from three different sections of the fecal sample . test the specimen while it is warm c.
headache and disorientation c. The client should be flat on bed for 6-8 hours with the legs straight to prevent? a. bleeding at the arterial puncture site .Answer: A A client with Swan-Ganz catheterization with a pressure dressing over the left groin. orthostatic hypotension b.
“Epidural anesthesia. “The procedure will be painful. regarding Doppler ultrasonography? a. “It requires a written consent.” d.” .” b. “It is a non-invasive procedure.Answer: C Which of the following statements made by the client reflects understanding.” c.
obtain a mucosal scrapping from the anterior urethra d.Answer: C A male client comes to the emergency room because he has discharge from his penis. instruct the client to provide a semen specimen b. swab the specimen as it appears on the prepuce c. teach the client how to obtain a clean catch specimen of urine . the nurse should: a. The doctor suspects gonorrhea and orders culture and sensitivity testing to aid with the diagnosis to obtain the culture.
c. .Answer: C What is the most effective method to obtain an accurate blood pressure on a client? a. identify the Korotkoff sounds. and take systolic reading at 10 mmHg after the first sound. d. use a cuff that is wide enough to cover the upper 2/3 of the client’s arm. obtain a cuff that covers the upper 1/3 of the client’s arm b. position the cuff approximately 4”above the antecubital space.
What is the best nursing action to decrease the temperature? a. place in a cool mist croupette with compressed air b. sponge trunk and extremities with tepid water c.60F.Answer: B A 4 month old client has a rectal temperature of 103. encourage to take clear liquids such as apple juice d. sponge with a solution containing half water and half water and half .
c.Answer: A What is important for the nurse to do in order to obtain a comprehensive medical history? a. document events and dates in . ask the most difficult questions first. ask about the family dynamics last. make sure the client is comfortable in his/her surroundings. b. d.
Answer: Which A of the following is more life threatening? A. BP = 180/100 B. BP = 80/50 . BP = 160/120 C. BP = 90/60 D.
weak pumping action of the heart increases cardiac output thus increasing Blood pressure .Answer: B Which of the following is TRUE about the blood pressure determinants? A. Arteriosclerosis increases blood pressure C. Hypervolemia lowers BP B. HCT of 70% might decrease or increase BP D.
Heavy alcohol consumption C. Dehydration .Answer: D Factors associated with hypertension include the following except: A.Thickening of the arterial walls B. Increase cholesterol levels D.
True low reading C. False low reading . True high reading B. C Too narrow cuff will cause what change in the Client’s BP? A.Answer: . False high reading D.
a BP of 160/80 is . 2-3 mmHg at a time C. Use the bell of the stethoscope since the blood pressure is a low.frequency sound B. If the BP is taken on the left leg using the popliteal artery pressure.Answer: D Which of the following is INCORRECT in assessing client’s BP? A. Inflate and deflate slowly. The sound heard during taking BP is known as KOROTKOFF sound D.
Answer: How B many minute/s is/are allowed to pass before making a re-reading after the first one? A. 15 B. 1 C. 5 D. 30 .
Phase 3 of Korotkoff’s sound is the softer blowing muffled sound that fades . Phase 1 of Korotkoff’ssound is the swishing or whooshing sound B. Sound produced by BP is considered as HIGH frequency sound D.Answer: B . Which of the following is TRUE about the auscultation of blood pressure? A. The bell of the stethoscope is use in auscultating BP C.
Age of the following primarily affects BP? A. Sex C.Answer: Which B B. Obesity . Stress D.
What is the correct Bladder size? A. At least 2/3 of the leg circumference C. At least ¾ of the limbs circumference .Answer: A The length of the bladder also affects the accuracy of BP measurements. At least 2/3 of the limbs circumference B.
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