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Questions 149

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Extract:


Question 1 of 5

A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?

Correct Answer: C

Rationale: PEEP can increase intrathoracic pressure, reducing venous return and causing hypotension (e.g., BP drop to 90/48), an undesirable effect requiring intervention.

Question 2 of 5

A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:

Correct Answer: B

Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring efficacy while minimizing toxicity; a level of 20 mcg/mL is within this range.

Question 3 of 5

An 82-year-old woman is being admitted to a long-term care facility. Her assigned nurse completes a full assessment, including calculating the risk for skin breakdown based on the Braden Scale. To determine a Braden Scale score, the nurse evaluates all of the following EXCEPT

Correct Answer: C

Rationale: The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Past history of skin breakdown is not a scored category.

Question 4 of 5

The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

Correct Answer: B

Rationale: Diazoxide can cause hyperglycemia, so monitoring blood glucose levels is essential during administration.

Question 5 of 5

A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?

Correct Answer: C

Rationale: PEEP can increase intrathoracic pressure, reducing venous return and causing hypotension (e.g., BP drop to 90/48), an undesirable effect requiring intervention.

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