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Questions 227

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Extract:


Question 1 of 5

An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?

Correct Answer: C

Rationale: This menu is lowest in sodium. Ideally, low fat milk would be available.

Question 2 of 5

A postoperative client is to be discharged today. She will need to change her dressing daily. Which statement she makes indicates that she understands the process?

Correct Answer: A

Rationale: Hand washing before and after dressing changes prevents infection, reflecting proper understanding.
Touching dressings, cleaning toward the incision, or improper disposal increase infection risk.

Question 3 of 5

A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101°F (38.3°C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?

Correct Answer: B

Rationale: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal - not hypotonic - saline solution.

Extract:

The mother's condition has deteriorated during labor and a cesarean section is required. Her husband is worried and anxious about the changed of plan and demand for an explanation.


Question 4 of 5

Who among the following should explain the procedure to the husband?

Correct Answer: A

Rationale: The surgeon, as the procedure performer, is best suited to explain the cesarean section.

Extract:

Thirty minutes after delivery the nurse finds that a mother's uterus is relaxed and the lochia is excessive.


Question 5 of 5

The fist action by the nurse should be to:

Correct Answer: D

Rationale: Massaging the uterus promotes contraction, reducing excessive lochia and preventing hemorrhage.

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