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Questions 158

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Question 1 of 5

The client is admitted with a diagnosis of chorioamnionitis. Which symptom is most likely to be present?

Correct Answer: A

Rationale: Chorioamnionitis an infection of the amniotic fluid and membranes typically causes maternal fever. Fetal macrosomia decreased contractions and hypotension are not primary symptoms.

Question 2 of 5

A client with a history of heart failure is receiving Spironolactone (Aldactone). The nurse should teach the client to:

Correct Answer: A

Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, so potassium-rich foods should be avoided. Sodium restriction, daytime dosing, and fluid management are secondary.

Question 3 of 5

A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct Answer: B

Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.

Question 4 of 5

A client has viral encephalitis and has been prescribed IV acyclovir (Zovirax). What nursing interventions should be used when administering the drug?

Question Image

Correct Answer: A, B, C, E

Rationale: Acyclovir requires slow infusion (
A) to prevent phlebitis, adequate hydration (
B) to reduce nephrotoxicity, monitoring for neurotoxicity (
C), and caution in renal insufficiency (E). Heart rate (
D) is unrelated.

Question 5 of 5

The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?

Correct Answer: C

Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.

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