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Questions 158

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Question 1 of 5

A post-operative client has an order for Demerol (meperidine) 75 mg and Phenergan (promethazine) 25 mg IM every 3-4 hours as needed for pain. The combination of the two medications produces a/an:

Correct Answer: B

Rationale: Meperidine (opioid) and promethazine (antihistamine) together produce a synergistic effect, enhancing pain relief and sedation. Promethazine potentiates meperidine’s effects.

Question 2 of 5

A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

Correct Answer: D

Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.

Question 3 of 5

A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:

Correct Answer: D

Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.

Question 4 of 5

A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:

Correct Answer: B

Rationale: This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.

Question 5 of 5

A client with a diagnosis of Amyotrophic Lateral Sclerosis (ALS) has been prescribed riluzole (Rilutek). Which does the nurse include when teaching the client about this drug?

Question Image

Correct Answer: A, C, D, E

Rationale: Riluzole teaching includes avoiding alcohol (
A), reporting fever (
C), consistent timing (
D), and regular lab monitoring (E). Taking with food (
B) is not required.

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