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Questions 158

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Question 1 of 5

A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?

Correct Answer: A

Rationale: Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. Urine specific gravity does not necessarily indicate fluid volume excess. Edema may not be apparent, yet the client may have fluid volume excess.

Question 2 of 5

The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:

Correct Answer: A

Rationale: This technique provides effective rinsing and gingival stimulation. This technique does not provide gingival stimulation. This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. This technique provides effective rinsing but not gingival stimulation.

Question 3 of 5

The nurse is caring for a client with a history of preterm labor. Which medication is most likely to be ordered to halt preterm contractions?

Correct Answer: B

Rationale: Nifedipine a calcium channel blocker is commonly used as a tocolytic to halt preterm contractions by relaxing uterine smooth muscle. Ritodrine is less used due to side effects magnesium sulfate is more for preeclampsia and indomethacin is used in specific cases.

Question 4 of 5

A client with a history of Addison's disease is admitted with complaints of nausea and vomiting. The nurse should expect the client to have:

Correct Answer: A

Rationale: Addison's disease causes adrenal insufficiency, reducing aldosterone, which leads to hyperkalemia due to impaired potassium excretion.

Question 5 of 5

The client tells the nurse, 'I have pain in my left shoulder.' This is considered:

Correct Answer: C

Rationale: Subjective information is provided by a person.

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