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Questions 158

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Question 1 of 5

A baby is circumcised. Immediate postoperative care should include:

Correct Answer: D

Rationale: A pressure diaper should be applied to discourage hemorrhage. The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. Dressing changes should not be dry. Dry dressing will stick. Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.

Question 2 of 5

The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?

Correct Answer: A

Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.

Question 3 of 5

Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

Correct Answer: A

Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.

Question 4 of 5

Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:

Correct Answer: C

Rationale: Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.

Question 5 of 5

The nurse is caring for a client who is recovering from a fractured femur. Which diet selection would be best for this client?

Correct Answer: D

Rationale: A diet for fracture recovery needs protein, calcium, and vitamin C. Mandarin orange salad (vitamin
C), broiled chicken (protein), and milk (calcium) (
D) are optimal. Other options are less nutrient-dense.

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