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Question 1 of 5

A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

Correct Answer: A

Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.

Question 2 of 5

A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

Correct Answer: A

Rationale: Maintaining O2 at <40% minimizes the risk of retrolental fibroplasia, a complication of high oxygen levels in premature infants.

Question 3 of 5

A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:

Correct Answer: D

Rationale: Using Nägele's rule (LMP - 3 months + 7 days + 1 year), August 3 leads to an estimated delivery date of May 10.

Question 4 of 5

A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?

Correct Answer: B

Rationale: These symptoms are found in clients with tardive dyskinesia.

Question 5 of 5

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Correct Answer: C

Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.

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