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Questions 164

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Question 1 of 5

A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?

Correct Answer: B

Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.

Question 2 of 5

The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:

Correct Answer: D

Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.

Question 3 of 5

An older adult is diagnosed with open-angle glaucoma. Which comment by the client indicates understanding of the management of the condition?

Correct Answer: A

Rationale: Daily eye drops control intraocular pressure in open-angle glaucoma, a chronic condition, indicating understanding, unlike expecting a cure, contagiousness, or immediate surgery.

Question 4 of 5

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

Correct Answer: C

Rationale: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

Question 5 of 5

A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?

Correct Answer: C

Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.

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