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Questions 227

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Extract:


Question 1 of 5

Order: Vancomycin HCl 1 g in 250 mL DW IVPB, infuse in 90 min. Calculate the flow rate in drops per minute. The drop factor is 20 gtt/mL.

Correct Answer: A

Rationale: 250 mL ÷ 90 min = 2.777 mL/min. 2.777 mL/min × 20 gtt/mL = 55.56 gtt/min, rounded to 56 gtt/min. Other options are incorrect.

Question 2 of 5

A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

Correct Answer: A

Rationale: Positive urine glucose and acetone suggest gestational diabetes mellitus (GDM), which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Pedal edema (
B), increased vaginal discharge (
C), and diaphragmatic pressure (
D) are common in late pregnancy and not typically concerning unless accompanied by other symptoms.

Question 3 of 5

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following findings would indicate a complication of TPN therapy?

Correct Answer: B

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia, a common TPN complication due to high dextrose content, requiring insulin adjustment or rate change. Weight gain (
A) is expected, low-grade fever (
C) is nonspecific, and normal urine output (
D) is unremarkable.

Question 4 of 5

A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

Correct Answer: C

Rationale: Laying a seizing child on their back risks aspiration; the correct position is on the side. The other statements reflect appropriate seizure management. Reduction of Risk Potential

Extract:

Marie is a 38-year-old primigravida who is admitted with a diagnosis of pregnancy induced hypertension (PIH).


Question 5 of 5

Priority nursing care on the patient with PIH include:

Correct Answer: C

Rationale: Low urine output (335 ml/24 hours) indicates possible renal involvement in PIH, a priority for monitoring and reporting to prevent further complications.

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