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Questions 158

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Question 1 of 5

A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?

Correct Answer: C

Rationale: The ABCs of trauma care prioritize airway establishment, followed by controlling hemorrhage and preventing shock, then assessing head injuries to ensure oxygenation and perfusion.

Question 2 of 5

A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.

Correct Answer: A

Rationale: Fluid volume deficit is the major problem. Symptoms of dehydration are evident, and rehydration is critical to prevent life-threatening complications.

Question 3 of 5

The nurse is teaching a client with a new colostomy about appliance care. Which instruction should be included?

Correct Answer: B

Rationale: Emptying the colostomy pouch when one-third to one-half full prevents leakage and skin irritation. Changing every 12 hours is excessive, soap may leave residue, and lotion can interfere with adhesion.

Question 4 of 5

A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?

Correct Answer: C

Rationale: 50 gtt/min.

Question 5 of 5

The nurse is caring for a client with a diagnosis of postpartum endometritis. Which medication is most likely to be ordered?

Correct Answer: B

Rationale: Postpartum endometritis is a bacterial infection of the uterus treated with antibiotics (e.g. ampicillin gentamicin). Magnesium sulfate methylergonovine and betamethasone are used for other obstetric conditions.

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