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Questions 149

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Question 1 of 5

An ICU nurse is caring for a client receiving total parenteral nutrition (TPN) via IV. The client's infusion ended 2 hours ago and the pharmacy has not yet sent another bag. The client is diaphoretic, tachycardic, and states he feels weak, dizzy, and fatigued. The nurse suspects

Correct Answer: D

Rationale: Abrupt cessation of TPN can cause hypoglycemia due to persistent insulin secretion, leading to diaphoresis, tachycardia, weakness, and dizziness.

Question 2 of 5

A client arrives from surgery following an abdominal perineal resection with a permanent ileostomy. What should be the priority nursing care during the post-op period?

Correct Answer: D

Rationale: Facilitating perineal wound drainage is the priority to prevent infection and promote healing in the immediate postoperative period, as the perineal wound is at high risk for complications.

Question 3 of 5

A client is being assessed for neutropenia. The client's total white blood cell count is 5200 with 45% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)? Record your answer using a whole number.

Correct Answer: 2600

Rationale: ANC = WBC X (Neutrophils% + Bands%) = 5200 X (0.45 + 0.05) = 5200 X 0.5 = 2600.

Question 4 of 5

During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:

Correct Answer: C

Rationale: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent obstruction or infection.

Question 5 of 5

A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:

Correct Answer: C

Rationale: An L/S ratio of 1:1 indicates immature fetal lungs, increasing the risk of respiratory distress syndrome, despite the presence of phosphatidylglycerol.

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