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Questions 149

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Question 1 of 5

A client pushes his call light and tells the nurse his chest is hurting. The nurse sees his oxygen saturation is 88%. The nurse's first intervention is to

Correct Answer: B

Rationale: Hypoxemia (SpO2 88%) requires immediate oxygen administration to improve oxygenation, which is the priority for chest pain before further assessment or intervention.

Question 2 of 5

A client weighing 150 pounds has received burns over 50% of his body at 1200 hours. Using the Parkland formula, calculate the expected amount of fluid that the client should receive by 2000 hours.

Correct Answer: B

Rationale: Parkland formula: 4 mL × kg × % TBSA. Weight = 150 lb ÷ 2.2 = 68 kg. 4 × 68 × 50 = 13,600 mL total. Half (6,800 mL) is given in the first 8 hours (1200 to 2000).

Question 3 of 5

A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:

Correct Answer: C

Rationale: TPN is a high-glucose solution, often causing hyperglycemia, necessitating sliding-scale insulin to manage blood glucose levels.

Question 4 of 5

The nurse is teaching a newly diagnosed client about Crohn's disease but discovers that the client has several barriers to learning. The nurse understands that socioeconomic barriers to learning include which factors? Select all that apply.

Correct Answer: B, D

Rationale: Low literacy and lack of access to health resources are socioeconomic barriers to learning, while cognitive delays and lack of interest are not strictly socioeconomic, and adequate insurance is not a barrier.

Question 5 of 5

Which of the following findings would be expected in the infant with biliary atresia?

Correct Answer: C

Rationale: Biliary atresia causes abdominal distention due to bile accumulation and poor weight gain due to malabsorption.

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