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Questions 164

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Question 1 of 5

A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to

Correct Answer: D

Rationale: Spare protein catabolism to meet metabolic needs. A high-carbohydrate diet prevents protein breakdown for energy, allowing proteins to restore tissue.

Question 2 of 5

The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?

Correct Answer: D

Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.

Question 3 of 5

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?

Correct Answer: D

Rationale: Calf asymmetry of 4 cm suggests deep vein thrombosis, a critical postoperative complication. Pain is nonspecific, negative Homan sign is unreliable, and varicose veins are less urgent.

Question 4 of 5

The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting recreational substances. The parents ask the nurse if the client will develop schizophrenia. Which response by the nurse is appropriate?

Correct Answer: C

Rationale: Schizophrenia risk cannot be predicted from a single episode; observation is needed. Reassurance , permanent effects , and blame are inaccurate.

Question 5 of 5

The nurse is administering a cleansing enema to a client the night before bowel surgery. When administering the enema, the client reports cramping and pain. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Pausing and slowing the flow reduces cramping by allowing the bowel to adjust. Raising the container increases pressure, reassurance doesn't address pain, and withdrawing the tube is unnecessary.

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