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Questions 158

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Question 1 of 5

A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?

Correct Answer: D

Rationale: The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. Gargles and vigorous toothbrushing could initiate bleeding. Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs.

Question 2 of 5

Which tasks should not be delegated to the unlicensed assistive personnel?

Question Image

Correct Answer: C

Rationale: Unlicensed assistive personnel (UAP) can perform basic care tasks like bathing (
A), perineal care (E), and assisting with feeding under supervision (
B). Basic life support (
D) may be within their scope if trained. However, administering parenteral medications (
C) requires assessment and judgment, which is beyond UAP scope and reserved for licensed nurses.

Question 3 of 5

A client with a history of a fractured femur is in skeletal traction. The nurse should:

Correct Answer: B

Rationale: Cleaning pin sites with saline (or per protocol) prevents infection in skeletal traction. Turning is limited, lotion is unnecessary, and removing weights disrupts traction.

Question 4 of 5

Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:

Correct Answer: A

Rationale: Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure during electroconvulsive therapy.

Question 5 of 5

Pregnant women with diabetes often have problems related to the effectiveness of insulin in controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this is due to:

Correct Answer: D

Rationale: There is a rise in glomerular filtration rate in the kidneys in conjunction with decreased tubular glucose reabsorption, resulting in glycosuria. Insulin is inhibited by increased levels of estrogen. Insulin is inhibited by increased levels of progesterone. Human placental lactogen levels increase later in pregnancy. This hormonal antagonist reduces insulin's effectiveness, stimulates lipolysis, and increases the circulation of free fatty acids.

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