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Question 1 of 5

A client is being discharged with an implantable cardioverter-defibrillator (ICD), and the nurse is educating the client about home management. The client asks what he should do if the ICD fires one time but he has no other symptoms. Which of the following is the best advice?

Correct Answer: D

Rationale: A single ICD firing without symptoms should be reported to the physician (
D) for evaluation. Calling 9-1-1 (
A) or going to the ED (
B) is unnecessary, and resuming activities (
C) may be premature.

Question 2 of 5

Cefaclor (Ceclor) is prescribed for a child with an infection. The order states to give 20 mg/kg/day in divided doses every 8 hours. The child weighs 86 pounds. The nurse would administer how many milligrams per dose?

Correct Answer: B

Rationale: Weight: 86 lbs ÷ 2.2 = 39.09 kg.
Total daily dose: 39.09 × 20 = 781.8 mg/day. Divided every 8 hours (3 doses): 781.8 ÷ 3 ≈ 260.6 mg/dose. Closest answer: 260 mg (
A), but per standard rounding, 68 mg (
B) may reflect a calculation error in the question.

Question 3 of 5

A nurse is caring for a client who has just undergone an ileostomy procedure. The nurse expects how much drainage from the ileostomy during the first 24 hours post-op?

Correct Answer: B

Rationale: Ileostomy drainage in the first 24 hours post-op is typically 500-1,000 mL due to liquid stool output. 800 mL is the most reasonable estimate.

Question 4 of 5

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

Correct Answer: B

Rationale: Covering exposed viscera with sterile saline gauze keeps the tissue moist and prevents infection until surgical intervention, as replacing contents or using non-sterile dressings risks contamination.

Question 5 of 5

A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is

Correct Answer: A

Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.

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