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Questions 158

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Extract:


Question 1 of 5

The best size cathlon for administration of a blood transfusion to a six-year-old is:

Correct Answer: D

Rationale: A 20-gauge catheter is appropriate for blood transfusions in a six-year-old balancing adequate flow rate and minimal vessel trauma. Smaller gauges (22) may be too small and larger gauges (18 19) are more invasive than necessary.

Question 2 of 5

A nurse should carefully monitor a client for the following side effect of MgSO4:

Correct Answer: D

Rationale: The nurse should provide good distractors because these symptoms indicate that PIH has become more severe and may precede the convulsive or eclamptic phase. This is the opposite side effect of this medication. This is a common side effect of this medication and needs to be monitored and recorded frequently.

Question 3 of 5

A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:

Correct Answer: C

Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.

Question 4 of 5

The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?

Correct Answer: A

Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.

Question 5 of 5

The postpartum nurse should include which of the following instructions to breast-feeding mothers?

Correct Answer: C

Rationale: Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.

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